BILL ANALYSIS                                                                                                                                                                                                    




          SENATE COMMITTEE ON EDUCATION
                              Senator Carol Liu, Chair
                                2015 - 2016  Regular 

          Bill No:             SB 277              
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          |Author:    |Pan and Allen                                        |
          |-----------+-----------------------------------------------------|
          |Version:   |April 9, 2015                               Hearing  |
          |           |Date:    April 15, 2015                              |
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          |Urgency:   |No                     |Fiscal:    |Yes              |
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          |Consultant:|Lynn Lorber                                          |
          |           |                                                     |
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          Subject:  Public health:  vaccinations

          NOTE:  This bill has been referred to the Committees on Health,  
                Education and Judiciary.  A "do pass" motion should  
                include referral to the Committee on Judiciary.

            SUMMARY
          
          This bill removes the ability for parents to file a personal  
          belief exemption from the requirement that children receive  
          vaccines for specific communicable diseases prior to being  
          admitted to any private or public elementary or secondary  
          school, child care center, day nursery, nursery school, family  
          day care home, or development center.

            BACKGROUND
          
          Current law:

          Compulsory education

             1.   Provides that each child between the ages of 6 and 18  
               years is subject to compulsory full-time education, and  
               requires attendance at the public full-time day school or  
               continuation school or classes for the full schoolday.

             2.   Requires parents and guardians to send the student to  








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               school for the full schoolday.  (Education Code  48200)

          Required immunizations

             3.   Prohibits the unconditional admission of a student to  
               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 the child's  
               first admission to that institution, the child has been  
               fully immunized. The following are the diseases for which  
               immunizations shall be documented:

                  A.        Diphtheria.

                  B.        Haemophilus influenzae type b.

                  C.        Measles.

                  D.        Mumps.

                  E.        Pertussis (whooping cough).

                  F.        Poliomyelitis.

                  G.        Rubella.

                  H.        Tetanus.

                  I.        Hepatitis B.

                  J.        Varicella (chickenpox).

                  AA.       Any other disease deemed appropriate by the  
                    California Department of Public Health, taking into  
                    consideration the recommendations of the Advisory  
                    Committee on Immunization Practices of the United  
                    States Department of Health and Human Services, the  
                    American Academy of Pediatrics, and the American  
                    Academy of Family Physicians.  
                    (Health and Safety Code  120335)

             1.   Prohibits schools from unconditionally admitting or  
               advancing any student to grade 7 unless the student has  








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               been fully immunized against pertussis, including all  
               pertussis boosters appropriate for the student's age.   
               Current law provides that full immunization against  
               hepatitis B shall not be a condition by which a school  
               admit or advance a student to the 7th grade.  (HSC   
               120335)

             2.   Authorizes school districts to permit specified licensed  
               health practitioners to administer an immunizing agent to a  
               student whose parent or guardian has consented in writing  
               to the administration of the immunizing agent.  (EC   
               49403)

          Personal belief exemption

             3.   Provides that immunization is not required for admission  
               to a school or other institution if the parent or guardian  
               files with the school a letter or affidavit that documents  
               which immunizations have been given and which immunizations  
               have not been given on the basis that they are contrary to  
               his or her beliefs.  

             4.   Requires, beginning January 1, 2014, a form prescribed  
               by the California Department of Public Health (CDPH) to  
               accompany the letter or affidavit.  

             5.   Requires the CDPH form to include both of the following:

                  A.        A signed attestation from the health care  
                    practitioner that indicates that the health care  
                    practitioner provided the parent or guardian with  
                    information 
                    regarding the benefits and risks of the immunization  
                    and the health risks of the communicable diseases to  
                    the child and the community.  

                  B.        A written statement signed by the parent or  
                    guardian that indicates that the signer has received  
                    the information provided by the health care  
                    practitioner.

                  C.        Authorizes schools or other institutions, when  
                    there is good cause to believe that the child has been  








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                    exposed to one of the communicable diseases, to  
                    temporarily exclude the child from attendance until  
                    the local health officer is satisfied that the child  
                    is no longer at risk of developing the disease.  (HSC  
                     120365)

          Medical exemption  

             1.   Provides that a child is exempt from immunization  
               requirements if the parent or guardian files with the  
               school or other institution 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  
               probably duration of the medical condition or circumstances  
               that contraindicate immunization.  (HSC  120370)

          Conditional admission
          
             2.   Authorizes a school or other institution to admit a  
               child who has not been fully immunized against one or more  
               of the communicable diseases on condition that the child  
               presents evidence that he or she has been fully immunized  
               against all of these diseases within time periods  
               designated by regulation of the California Department of  
               Public Health (CDPH).  
               (HSC  120340)

             3.   Requires a school or other institution to exclude from  
               further attendance any child who fails to obtain the  
               required immunizations within no more than 10 schooldays  
               following receipt of the notice that the child does not  
               meet immunization requirements, unless the child is exempt  
               for medical reasons or personal beliefs, until the child  
               provides written evidence that he or she has received  
               another dose of each required vaccine due at that time.   
               Regulations require any child so excluded to be reported to  
               the attendance supervisor or to the building administrator.  
                (California Code of Regulations (CCR), Title 17,  6055)

          Temporary exclusion









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             4.   Authorizes a child for whom the immunization requirement  
               has been waived, whenever there is good cause to believe  
               that he or she has been exposed to one of the communicable  
               diseases, to be temporarily excluded from the school or  
               other institution until the local health officer is  
               satisfied that the child is no longer at risk of developing  
               the disease.  (HSC  120365)

             5.   Requires county offices of education and school  
               districts to exclude any student who has not been immunized  
               as required by the Health and Safety Code, and requires the  
               school to notify the parent or guardian that they have two  
               weeks to 
          supply evidence either that the student has been fully  
          immunized, or that the student is exempted from the immunization  
          requirement.  (EC  48216)

             6.   Provides that an already admitted child who is  
               subsequently discovered not to have received all the  
               immunizations which were required before admission or who  
               is subsequently discovered not to have complied with the  
               requirements for conditional admission is to continue in  
               attendance only if he or she receives all vaccine doses for  
               which he or she is currently due and provides documentation  
               of having received such doses no later than 10 school days  
               after he or she or the parent or guardian is notified.   
               Regulations require a school or other institution to notify  
               the child or the parent or guardian of the time period (no  
               longer than 10 school days) within which the doses must be  
               received.  (CCR  6040)

            ANALYSIS
          
          This bill removes the ability for parents to file a personal  
          belief exemption from the requirement that children receive  
          vaccines for specific communicable diseases prior to being  
          admitted to any private or public elementary or secondary  
          school, child care center, day nursery, nursery school, family  
          day care home, or development center.  Specifically, this bill:

          1.   Deletes the exemption from immunization requirements for  
               personal beliefs and requirement that a parent or guardian:









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                    A.             File a letter or affidavit stating  
                    which immunizations the child has not been given.

                    B.             Also provide a form prescribed by the  
                    California Department of Public Health including both  
                    of the following:

                           i)                  A signed attestation from  
                         the health care practitioner indicating that the  
                         health care practitioner provided information  
                         regarding the benefits and risks of the  
                         immunization and the health risks of the  
                         communicable diseases to the child and the  
                         community.

                           ii)     A written statement signed by the  
                         parent or guardian that the signer has received  
                         the information provided by the health care  
                         practitioner.

          2.   Exempts from immunization requirements a home-based private  
               school if all of the students are residents of the  
               household or are members of a single family.

          3.   Expands existing annual notification requirements for  
               school districts to include notification to parents or  
               guardians of the immunization rates for each of the  
               required immunizations for the school in which a student is  
               enrolled.

          STAFF COMMENTS
          
          1.   Need for the bill.  According to the authors, "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 Centers for Disease Control  
               and Prevention, there were more cases of measles in January  
               2015 in the United States than in any one month in the past  
               20 years.  Measles has spread through California and the  
               United States, in large part, because of communities with  
               large numbers of unvaccinated people.  Between 2000 and  








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               2012, the number of Personal Belief Exemptions (PBE) from  
               vaccinations required for school entry that were filed rose  
               by 337%.  In 2000, the PBE rate for Kindergartners entering  
               California schools was under 1%.  However, as of 2012, that  
               number rose to 2.6%.  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%.  In certain pockets of  
               California, exemption rates are as high as 21% 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% are necessary to preserve  
               herd immunity and prevent future outbreaks."
          
          2.   Recent amendments.  This bill was amended on April 9 to  
               include amendments discussed and informally adopted by the  
               Senate Health Committee during the April 8 hearing.  The  
               amendments:

               A.        Exempt homeschools if all of the students are  
                    residents of the household or are members of a single  
                    family.

               B.        Reinsert and relocate current law regarding the  
                    authority for schools to temporarily exclude a child  
                    with a personal belief exemption when there is good  
                    cause to believe that child has been exposed to one of  
                    the communicable diseases.

          3.   Vaccine safety and related issues.  This bill was heard by  
               the Senate Health Committee on April 8.  Please refer to  
               the Senate Health Committee analysis for information  
               regarding vaccine safety, the entities that recommend  
               vaccines, the measles outbreak, and laws in other states.

          4.   Vaccination rates and community immunity.  According to the  
               United States Department of Health and Human Services,  
               "when a critical portion of a community is immunized  
               against a contagious disease, most members of the community  
               are protected against that disease because there is little  
               opportunity for an outbreak.  Even those who are not  
               eligible for certain vaccines, such as infants, pregnant  
               women, or immunocompromised individuals, get some  








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               protection because the spread of contagious disease is  
               contained. This is known as 'community immunity.'" 

          According to California Department of Public Health (CDPH's)  
               2014-15 Kindergarten Immunization Assessment Results, the  
               statewide immunization coverage remained above 92% for each  
               vaccine for all schools since last year.  However, CDPH's  
               school level data files show that many individual schools  
               have much lower rates of fully immunized students.   
                http://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationL 
               evels.aspx  

          The authors and proponents express concern about localized  
               vaccination rates, rather than statewide rates.  Some  
               opponents of this bill suggest it would be more appropriate  
               to provide additional resources and/or compliance  
               incentives in geographic areas where community immunity  
               levels have not been achieved.

          5.   Compulsory education, public health and personal rights.   
               Current law requires each child between the ages of 6 and  
               18 years to attend school for the full schoolday, and  
               requires parents to compel children to attend school.   
               Truancy laws provide various levels of intervention and  
               punishment for both students and parents.  

          The United States Supreme Court has ruled that states may use  
               their "police power" to require vaccinations, including  
               vaccinations for children entering schools.   
                http://fas.org/sgp/crs/misc/RS21414.pdf  

          The American Civil Liberties Union writes with concerns to this  
               bill: "Unlike other states, public education is a  
               fundamental right under the California Constitution.  
               (Serrano v. Priest, 5 Cal.3d 584 (1971); Serrano v. Priest,  
               18 Cal.3d 728 (1976).) 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."

          The issues of police power, compelling state interest, and other  
               legal matters may be more appropriately considered by the  
               Senate Judiciary Committee.  Considering the jurisdiction  








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               of the Senate Education Committee, this Committee may wish  
               to consider issues specific to the role of schools in  
               providing a safe and appropriate educational opportunity  
               for each student.

          6.   What options will parents have?  It appears that, if this  
               bill were to become law, parents or guardians who do not  
               vaccinate their children as required by the Health and  
               Safety Code would be limited to homeschooling or risk  
               violating truancy laws.  

          This bill affects private schools.  The State compels each  
               student to attend school and provides opportunities for  
               attendance at public schools.  Should this bill be limited  
               to public schools to enable attendance at private schools  
               that may choose to enroll students who are not fully  
               vaccinated?

          7.   Reasonable timeline?  This bill will become effective on  
               January 1, 2016, if it becomes law.  Will schools  
               immediately require students to be fully vaccinated, or  
               will existing personal belief exemptions be valid for the  
               remainder of this 
               school year?  Will students who have no vaccinations have  
               enough time to catch-up to full vaccination?  The author  
               may wish to consider a phased-in approach.

          8.   Fiscal impact.  To the extent that parents remove their  
               children from public schools, this bill could impose  
               significant costs on school districts, as a portion of  
               school funding is based on average daily attendance.   
               However, to the extent that students are not absent due to  
               illnesses, this bill could create cost savings to school  
               districts.  

          9.   Personal belief exemption.  Children with a personal belief  
               exemption are not necessarily without any vaccines, but  
               likely are not fully vaccinated.  

          According to California Department of Public Health (CDPH's)  
               2014-15 Kindergarten Immunization Assessment Results, the  
               statewide percentage of personal belief exemptions had  
               consistently increased annually among all reporting schools  








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               until 2014-15, when there was a 19% decrease compared with  
               last year.  While public school personal belief exemption  
               rates decreased by 21% (from 2.92% to 2.31%), private  
               school personal belief exemption rates decreased only 9%  
               (from 5.88% to 5.33%).  
                http://www.cdph.ca.gov/programs/immunize/Documents/2014-15%2 
               0CA%20Kindergarten%20Immunization%20Assessment.pdf  

          California's personal belief exemption covers all beliefs,  
               including religious; there is not a separate exemption  
               specific to religion.  Therefore, this bill eliminates the  
               ability of parents or guardians to seek exemption from  
               immunization requirements based on religious beliefs.

          Governor Brown included a signing message related to AB 2109  
               (Pan, Ch. 821, 2012), which reads in part:  

                    I am signing AB 2109 and am directing the  
                    Department of Public Health to oversee this  
                    policy so parents are not overly burdened in its  
                    implementation.  Additionally, I will direct the  
                    department 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.

               It is unclear whether California Department of Public  
               Health (CDPH) is working to develop a separate  
               religious exemption.  

          10.  Medical exemption.  Current law exempts from  
               immunization requirements children whose parent or  
               guardian have filed with the school or other  
               institution a written statement by a licensed  
               physician to the effect that the physical condition or  
               medical circumstances are such that immunization is  
               not considered safe.  Some opponents maintain that a  
               medical exemption is very difficult to obtain,  
               especially if the medical concern is not overtly  
               severe.  The decision whether to grant a medical 
          exemption from immunizations is at the discretion of each  
          physician.  It is unclear if guidelines for physicians are  








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          available.

          11.  Vaccination requirements.  The Centers for Disease Control  
               and Prevention recommend a schedule of immunizations for  
               children from birth through age 18.  
           http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-sch 
               edule.pdf  

          The California Department of Public Health (CDPH) determines  
               which immunizations children must have, and at what age,  
               before being unconditionally admitted to a private or  
               public school or licensed child care program.  

          For child care:   http://www.shotsforschool.org/child-care/  

          For K-12 schools:   http://www.shotsforschool.org/k-12/  

          12.  Hepatitis B.  Some opponents of this bill question the need  
               for the Hepatitis B vaccination, and point to the right of  
               attendance for students who are infected with HIV.   
               According to the Centers for Disease Control and  
               Prevention, children can become infected by contact with  
               blood and body fluids through breaks in the skin such as  
               bites, cuts, or sores; by contact with objects that have  
               blood or body fluids on them such as toothbrushes, razors;  
               by having unprotected sex; and by sharing drug needles.  Is  
                         there a reasonable analogy between allowing the attendance  
               of a student infected with HIV and allowing the attendance  
               of a student who has not been fully vaccinated against  
               Hepatitis B?  Do parents need to worry about students being  
               exposed to Hepatitis B while at school or child care?

          13.  Reporting.  This bill requires school districts to include  
               in the annual notification to parents at the beginning of  
               the schoolyear the immunization rates for each of the  
               required immunizations for the school in which a student is  
               enrolled.

          Schools and licensed child care providers annually submit rates  
               of immunizations to the CDPH.  Data submitted includes the  
               rates for each required vaccine, personal belief  
               exemptions, permanent medical exemptions, and conditional  
               entrants.   








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                http://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationR 
               atesatCaliforniaSchools.aspx  

               The authors may wish to consider instead requiring the  
               annual notification to parents to include a link to the  
               CDPH website and a date when the current data will be  
               available on CDPH's website.

          14.  Related and prior legislation. 

          RELATED LEGISLATION

          SB 792 (Mendoza, 2015) prohibits a person from being employed at  
               a day care center or family day care home, if that person  
               has not been immunized against 
               influenza, pertussis, and measles.  SB 792 is scheduled to  
               be heard by the Senate Health Committee on April 15.

               PRIOR LEGISLATION

               AB 2109 (Pan, Ch. 821, 2012) requires, beginning January 1,  
               2014, a separate form prescribed by the California  
               Department of Public Health (CDPH) to accompany a letter or  
               affidavit from a parent or guardian to exempt a child from  
               immunization requirements on the basis that the  
               immunization is contrary to beliefs of the child's parent  
               or guardian.

               SB 614 (Kehoe, Ch. 123,  2011) authorizes a student in  
               grades 7- 12 to conditionally attend school for up to 30  
               calendar days beyond the student's first day of attendance  
               for the 2011-12 school year, if that student has not been  
               fully immunized with all pertussis boosters appropriate for  
               the student's age if specified conditions are met.

               AB 354 (Arambula, Ch. 434, 2010) allows CDPH 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 CDPH must consider when updating the list  
               of required vaccinations.  AB 354 requires students  
               entering grades 7-12 to receive a TDaP booster prior to  
               admittance to school.








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               SB 1179 (Aanestad, 2008) deleted CDPH'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  
               failed passage in the Senate Health Committee.

               AB 2580 (Arambula, 2008) required students entering grade 7  
               to be fully immunized against pertussis. AB 2580 was held  
               on the Senate Appropriations Committee's suspense file.

               SB 676 (Ridley-Thomas, of 2007) required students entering  
               grade 7 to be fully immunized against pertussis. SB 676 was  
               held on the Assembly Appropriations Committee's suspense  
               file. 

               SB 533 (Yee, 2007) added pneumococcus to the list of  
               required immunizations for children. SB 533 was vetoed by  
               the Governor, whose veto message read:

                    While I am a strong proponent of prevention and  
                    support efforts to improve vaccine rates for  
                    children, I am unable to sign this bill as  
                    California's public health experts believe it is  
                    not needed.  The Department of Public Health can  
                    already require that young children receive the  
                    pneumococcal vaccine.  California's vaccine  
                    experts have not established a mandate 
                    as they believe it is not needed.  Approximately  
                    86 percent of children are already being  
                    vaccinated under a voluntary system.
          
            SUPPORT (most are specific to the prior version of the bill)
          
          California Association for Nurse Practitioners
          California Chapter of the American College of Emergency  
          Physicians
          California Coverage & Health Initiatives
          California Medical Association
          California Primary Care Association
          California School Boards Association
          California School Nurses Organization








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          CAPG
          Children Now
          Children's Defense Fund-California
          County Health Executives Association of California
          Health Officers Association of California
          Kaiser Permanente 
          Los Angeles County Board of Supervisors
          Reed Union School District
          The Children's Partnership
          Vaccinate California
          Numerous individuals


            OPPOSITION (specific to the prior version of the bill)
           
           Association of American Physicians and Surgeons
          AWAKE California
          California Chiropractic Association
          California Coalition for Health Choice
          Californians for Freedom of Choice
          California Nurses for Ethical Standards
          Educate.  Advocate.
          Homeschool Association of California
          National Autism Association of California
          Pacific Justice Institute
          ParentalRights.Org
          Plumas Charter School
          Safe Minds
          Standing Tall Chiropractic
          The Canary Party
          Unblind My Mind
          Numerous individuals
                                      -- END --