BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: SB 277 --------------------------------------------------------------- |AUTHOR: |Pan and Allen | |---------------+-----------------------------------------------| |VERSION: |February 19, 2015 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |April 8, 2015 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Melanie Moreno | --------------------------------------------------------------- SUBJECT : Public health: vaccinations SUMMARY : Eliminates the personal belief exemption from the requirement that children receive specified vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school or day care center. 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 the Department of Public Health (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 immunization requirements if the parent or guardian files with the governing authority a written statement by a licensed physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or SB 277 (Pan and Allen) Page 2 of ? circumstances that contraindicate immunization. 4.Waives the above immunization 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 with the governing authority stating that the immunization is contrary to his or her beliefs. 5.Requires a separate form prescribed by DPH to accompany a letter or affidavit to exempt a child from immunization requirements on the basis that an immunization is contrary to beliefs of the child's parent or guardian. Requires the form to include: a. A signed attestation from the health care practitioner that indicates that the parent or guardian of the person who is subject to the immunization requirements, the adult who has assumed responsibility for the care and custody of the person, or the person if an emancipated minor, was provided with information regarding the benefits and risks of the immunization and the health risks of the communicable diseases listed above to the person and to the community. Requires the attestation to be signed not more than six months before the date when the person first becomes subject to the immunization requirement for which exemption is being sought. b. A written statement signed by the parent or guardian of the person who is subject to the immunization requirements, the adult who has assumed responsibility for the care and custody of the person, or the person if an emancipated minor, that indicates that the signer has received the information provided by the health care practitioner pursuant a) above. Requires the statement to be signed not more than six months before the date when the person first becomes subject to the immunization requirements as a condition of admittance. 6.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 be temporarily excluded from the school or institution until SB 277 (Pan and Allen) Page 3 of ? the local health officer is satisfied that the child is no longer at risk of developing the disease. This bill: 1.Deletes the exemption for personal beliefs in #4 above and related existing law requiring a specified form to accompany a letter to exempt a child from immunization requirements on the basis that an immunization is contrary to beliefs of the child's parent or guardian. 2.Requires school districts, at the beginning of the first semester or quarter of the regular school term, to notify parents or guardians of students of the immunization rates for the school in which a pupil is enrolled, as specified. FISCAL EFFECT : This bill has not yet been analyzed by a fiscal committee. COMMENTS : 1.Author's statement. According to the author, in early 2015, California became the epicenter of a measles outbreak which was the result of unvaccinated individuals infecting vulnerable individuals including children who are unable to receive vaccinations due to health conditions or age requirements. According to the CDC, there were been more cases of measles in January 2015 in the U.S. than in any one month in the past 20 years. Measles has spread through California and the U.S., in large part, because of communities with large numbers of unvaccinated people. Between 2000 and 2012, the number of Personal Belief Exemptions (PBE) from vaccinations required for school entry that were filed rose by 337 percent. In 2000, the PBE rate for Kindergartners entering California schools was under one percent. However, as of 2012, that number rose to 2.6 percent. From 2012 to 2014, the number of children entering Kindergarten without receiving some or all of their required vaccinations due to their parent's personal beliefs increased to 3.15 percent (a 25 percent increase over the previous two years). In certain pockets of California, exemption rates are as high as 21 percent which places our communities at risk for preventable diseases. Given the highly contagious nature of diseases such as measles, vaccination rates of up to 95 percent are necessary to preserve herd immunity and prevent future outbreaks. SB 277 (Pan and Allen) Page 4 of ? 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. 3.ACIP. According to ACIP, it consists of 15 experts who are voting members and are responsible for making vaccine recommendations. The Secretary of the U.S. Department of Health and Human Services selects these members after an application, interview, and nomination process. Fourteen of the members have expertise in vaccinology, immunology, pediatrics, internal medicine, nursing, family medicine, virology, public health, infectious diseases, and/or preventive medicine; one member is a consumer representative who provides perspectives on the social and community aspects of vaccination. 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 vaccine-preventable diseases and to increase the safe usage of vaccines and related biological products. ACIP, along with AAP, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, approved the 2015 Recommended Immunization Schedules for Persons Aged 0 Through 18 Years. Children under SB 277 (Pan and Allen) Page 5 of ? 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 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 SB 277 (Pan and Allen) Page 6 of ? 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 June 2014, 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 childcare enrollees), New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Texas, Utah, Vermont, Washington, West Virginia and Wisconsin) permit philosophic exemptions. As of February, several state legislatures had introduced bills that would address non-medical exemptions. In addition to California, legislators in Oregon, Vermont, and Washington proposed to remove philosophical/personal belief exemption this year. Those bills were tabled in Oregon and Washington. 6.California vaccination rates. According to an August 2014 DPH fact sheet, vaccination coverage in California is at or near all-time high levels. DPH states that the implementation of current vaccine requirements has been effective in maintaining greater than or equal to 92 percent immunization coverage among children in licensed child care facilities and kindergartens. The DPH Immunization Branch maintains data on its website related to vaccination rates and is searchable statewide and by school (kindergarten and 7th grade rates) and child care facility. For school year 2014-15, DPH reported that 90.4 percent of the 535,332 students enrolled in reporting kindergartens received all required immunizations, which is a 0.2 percent increase from last year. In addition, the percentage of conditional entrants increased by 0.4 percent from last year. The percentage of students with permanent medical exemptions (PMEs) stayed the same at 0.19 percent, and there was a 0.61 percent decrease in students with PBEs compared with last year. Immunization coverage remained above 92 percent for each vaccine for all schools since last year. 7.California measles outbreak. The authors point to an outbreak of measles that began in December 2014 in Disneyland (Orange County) as one of the reasons for the introduction of this bill. There have been 134 confirmed measles cases reported in California residents as part of this outbreak. The latest confirmed measles case had rash onset on March 2nd, and DPH will consider the outbreak over when 42 days have elapsed from SB 277 (Pan and Allen) Page 7 of ? the end of the infectious period of the last known measles cases that was a not a new importation. As of the most recent DPH Surveillance Update, that date will be April 17, 2015. Of the confirmed cases: 40 cases visited Disneyland between December 17 and 20 where they are presumed to have been exposed to measles; 30 are household or close contacts to a confirmed case; 11 were exposed in a community setting (e.g., emergency room) where a confirmed case was known to be present; 50 have an unknown exposure source but are presumed to be linked to the outbreak based on a combination of descriptive epidemiology or strain type; and, three cases are known to have a different genotype from the outbreak strain. The ages of those infected with the measles during this outbreak varied, with 56 percent being 20 years or older, 18 percent were between the ages of five and 19, 15 percent were ages one to four, and 11 percent were under the age of one. Among measles cases for whom DPH have vaccination documentation, 57 were unvaccinated and 25 had one or more doses of MMR vaccine. 8.Triple referral. This bill has been triple referred to the Committees on Health, Education, and Judiciary. Should it pass out of this Committee, it will be heard in Senate Education Committee next. 9.Related legislation. SB 792 (Mendoza) would prohibit a person from being employed at a day care center or day care home unless he or she has been immunized against influenza, pertussis, and measles. SB 792 is set to be heard in this Committee on April 15, 2015. 10.Prior legislation. SB 2109 (Pan), Chapter 821, Statutes of 2012, requires, on and after January 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 an immunization is contrary to beliefs of the child's parent or guardian. Requires the form to include: a. A signed attestation from the health care practitioner that indicates that the parent or guardian of the person who is subject to the immunization requirements, the adult who has assumed responsibility for the care and custody of the person, or the person if an emancipated minor, was provided with information SB 277 (Pan and Allen) Page 8 of ? regarding the benefits and risks of the immunization and the health risks of the communicable diseases listed above 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, the adult who has assumed responsibility for the care and custody of the person, or the person if an emancipated minor, that indicates that the signer has received the information provided by the health care practitioner pursuant a) above. The Governor included a message with his signature on this bill, which stated, in part: "I will direct (DPH) to allow for a separate religious exemption on the form. In this way, people whose religious beliefs preclude vaccinations will not be required to seek a health care practitioner's signature." 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 the Assembly Appropriations Committee suspense file. 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 SB 277 (Pan and Allen) Page 9 of ? 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 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. 11.Support. Vaccinate California, the sponsor of this bill, writes that there is an overwhelming scientific consensus that vaccines work, and vaccines prevent terrible diseases that kill and maim. Vaccinate California states that when too many people forego vaccines, everyone is put at risk since no vaccine is 100 percent effective, and there are always people too young or too frail to be vaccinated. Vaccinate California asserts that experts can explain the science in detail, but the bottom line is that even though vaccine-refusers are small in number, their impact on the state is huge, and it is scary. SB 277 (Pan and Allen) Page 10 of ? The Health Officers Association of California (HOAC) states that despite the effectiveness of vaccines, California's public health departments have seen a rise in vaccine-preventable diseases such as pertussis and measles largely because many residents are choosing to selectively immunize or opt out of vaccinating their children. HOAC writes that these decisions risk the health of the community and can be particularly detrimental, even fatal, to newborns, infants, toddlers, and those living with immunocompromising health conditions. The Los Angeles County Board of Supervisors states that increased immunizations of school children can avoid preventable illnesses that could result in additional visits to hospital emergency rooms. The California Medical Association states that vaccines have undergone significant rigorous scientific review and continue to have ongoing safety tracking and that this indisputably shows that vaccines are effective and have very low risks. The California School Nurses Organization states that changing the school entry requirement to a medical exemption only will serve the public and schools well as "community immunity" varies by vaccine but it provides protection for those students and staff who, for medical reasons are unable to be vaccinated or are immunocompromised. California Coverage & Health Initiatives, Children NOW, The Children's Partnership, and Children's Defense Fund write that benefits of immunizations outweigh costs, and the social and direct economic costs of ensuring each child receives the ACIP recommended schedule of vaccines far outweighs the costs of not providing routine immunizations. This coalition states that it is estimated that for every $1 spent on immunizations, as many as $29 can be saved in direct and indirect costs. The California State PTA recognizes that there are children in our schools who cannot receive vaccines and immunizations due to medical reasons and are therefore susceptible to diseases should an outbreak occur, and it is our duty as a community protect vulnerable children and families by vaccinating those children who can be vaccinated. The California Immunization Coalition writes that although AB 2109 helped tighten up the personal belief exemption process, it is not enough and California needs to take stronger measures to protect children in our schools and in our communities. Insurance Commissioner Dave Jones writes that that the higher number of unvaccinated students is jeopardizing public health not only in schools but in the broader community, and that we need to take steps to keep schools safe and students healthy by preventing serious SB 277 (Pan and Allen) Page 11 of ? and potentially life-threatening diseases. 12.Support if amended. The Marin County Board of Supervisors writes that in order to address concerns of parents who home school their children in their own home, they request that this bill be amended to clarify that it does not apply in a home school setting. 13.Concerns. The ACLU of California writes that while they appreciate that vaccination against childhood diseases is a prudent step that should be promoted for the general welfare, they do not believe there has been a sufficient showing of need at present to warrant conditioning access to education on mandatory vaccination for each of the diseases covered by this bill. ACLU of California writes that unlike other states, public education is a fundamental right under the California Constitution, and equal access to education must therefore not be limited or denied unless the State demonstrates that its actions are "necessary to achieve a compelling state interest." ACLU of California writes that this bill does not declare what this interest might be, nor does it explain why denying students access to education is necessary to advance that interest. If there is, in fact, a compelling governmental interest in mandating that all students in every school be vaccinated against each of the enumerated diseases except for medical reasons, the bill should be amended to explain specifically what that interest is, where it exists, and under what conditions and circumstances it arises. ACLU of California further states that the reforms enacted by AB 2109 had been in effect for only about 12 months before this bill was announced, and that those reforms should be allowed an opportunity to work before they are stricken and replaced by an approach that restricts the fundamental right to education. If AB 2109 is thought not to be working, its effects should be analyzed and any deficiencies should be corrected. If for example herd-immunity levels have not been achieved for certain diseases in geographic areas where school districts may not be not fully complying with the law, those districts should be provided with additional resources and/or compliance incentives. ACLU of California writes that in some cases it appears the deficiencies may reflect a need for better data-keeping and reporting, rather than the actual rate of vaccinations. It has been reported for example that in just one week the Los Angeles Unified School District SB 277 (Pan and Allen) Page 12 of ? increased its vaccination rates significantly after the recent measles outbreak by temporarily hiring additional staff to replace nursing and clerical staff that had been laid off. Other media reports indicate that some districts may not be complying with existing law because there is no penalty and no mechanism for enforcement. ACLU of California states that in any event, herd immunity is a concept that applies to the entire population in a geographic area, not simply to public school students. 14.Opposition. The Association of American Physicians and Surgeons Inc. state that the need for informed consent is a firmly established principal of medical ethics and human rights and that the state has no right to force medical interventions on people without their consent. ParentalRights.Org contends that this measure violates the fundamental right of parents to direct the care and upbringing of their child and that it disenfranchises children whose parents oppose vaccinations from receiving free public education as provided by their parents' taxes. The California Chiropractic Association mentions that the Mayo Clinic warns against undermining the principle of informed consent in favor of universal vaccination and further states we ought not let a handful of measles cases at Disneyland turn into a full-scale assault on civil and human rights in America. The National Vaccine Information Center argues that it's particularly disturbing that physicians in the American Medical Association Code of Ethics affirm philosophical and religious exemptions for themselves yet want to remove this right for California parents. The Pacific Justice Institute argues that statewide vaccination rates exceed the threshold for herd immunity and, to the extent that a few communities have fallen below vaccination levels needed for herd immunity, the Legislature could consider approaches that allow greater local decision-making and accountability rather than imposing across-the-board statewide mandates. Families for Early Autism Treatment contend that this bill is contrary to the rights protected by the State and Federal Constitutions as it denies rights to privacy, education, free assembly, religious expression, consensual use of one's physical body and liberty. Educate. Advocate. writes that every medical intervention has both benefits and risks and that parents, not the State of California, have the right to decide which medical interventions their children receive. The Canary Party maintains that the United States Justice System deems each and SB 277 (Pan and Allen) Page 13 of ? every vaccine on the market as "unavoidably unsafe", which means that even when used as directed, someone will be harmed, or may even die from the vaccine. The Capitol Resource Institute notes that following the passage of AB 2109 the personal belief exemption rate fell from 3.1 percent in 2013 to 2.5 percent in 2014 after only a partial implementation of the law, and that this bill is far reaching and unnecessary. The Homeschool Association of California states this bill will negatively impact the freedom to homeschool and would make it impossible for many families to choose to homeschool legally. They argue that almost all homeschooling families use a legal option that involves attendance at some form of public or private school, either operated by a third party or operated by parents who file a private school affidavit, yet current law requires children admitted to private schools be fully vaccinated in accordance with existing law. 15.Oppose unless amended. California Naturopathic Doctors Association (CNDA) states that it supports immunization for the prevention of disease and the public health objective of achieving high rates of immunity to infectious disease. CNDA states that as licensed primary care doctors who can diagnose medical conditions such as anaphylaxis and immunodeficiency, reasons outlined in the CDC's list of contraindications to common pediatric vaccinations, naturopathic doctors must also be able to sign medical waivers for vaccination, when such medical conditions exist. CNDA opposes this bill unless it is amended to include NDs as providers who can sign medical waivers for vaccination. 16.Amendments. The author requests that the committee approve the following amendments: a. On page 5, delete lines 17-25, and move language contained in lines 26-31 to HSC 120370. b. On page 5,beginning on line 26: (b) When there is good cause to believe thatthea person who has not filed proof of immunization has been exposed to one of the communicable diseases listed in subdivision of Section 120325 c. Add a new section: 120335 (b) "The governing authority shall not unconditionally admit any person as a pupil of any SB 277 (Pan and Allen) Page 14 of ? 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. This section shall not apply to home-based private schools whose students are all members of the household or all members of a single family." SUPPORT AND OPPOSITION : Support: Vaccinate California (sponsor) American Academy of Pediatrics American Lung Association Biocom California Association of Nurse Practitioners California Chapter of the American College of Emergency Physicians California Children's Hospital Association California Coverage and Health Initiatives California Immunization Coalition California Medical Association California Optometric Association California School Nurses Organization California State Parent-Teacher Association Children Now Children's Defense Fund California Children's Specialty Care Coalition County of Los Angeles County of Santa Cruz Health Officers Association of California Insurance Commissioner Dave Jones Kaiser Permanente March of Dimes California Chapter Providence Health and Services Southern California San Francisco Unified School District Secular Coalition for California Silicon Valley Leadership Group Solano Beach School District The Children's Partnership Hundreds of individuals Oppose: Association of American Physicians and Surgeons SB 277 (Pan and Allen) Page 15 of ? California Chiropractic Association California Naturopathic Doctors Association (unless amended) California Nurses for Ethical Standards California ProLife Council California Right to Life Committee, Inc. Canary Party Capitol Resource Institute Educate. Advocate. Families for Early Autism Treatment Homeschool Association of California National Vaccine Information Center Pacific Justice Institute Center for Public Policy ParentalRights.org SafeMinds Hundreds of individuals -- END --