BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 277
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|AUTHOR: |Pan and Allen |
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|VERSION: |February 19, 2015 |
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|HEARING DATE: |April 8, 2015 | | |
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|CONSULTANT: |Melanie Moreno |
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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
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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
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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
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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
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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
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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 that the a
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
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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
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