BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 277| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- THIRD READING Bill No: SB 277 Author: Pan (D) and Allen (D), et al. Amended: 5/7/15 Vote: 21 SENATE HEALTH COMMITTEE: 6-2, 4/8/15 AYES: Nguyen, Hall, Mitchell, Monning, Pan, Wolk NOES: Nielsen, Roth NO VOTE RECORDED: Hernandez SENATE EDUCATION COMMITTEE: 7-2, 4/22/15 AYES: Liu, Block, Hancock, Mendoza, Monning, Pan, Vidak NOES: Runner, Leyva SENATE JUDICIARY COMMITTEE: 5-1, 4/28/15 AYES: Jackson, Hertzberg, Leno, Monning, Wieckowski NOES: Anderson NO VOTE RECORDED: Moorlach SUBJECT: Public health: vaccinations SOURCE: Vaccinate California DIGEST: This bill eliminates the personal belief exemption from the requirement that children receive vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school or day care center. ANALYSIS: SB 277 Page 2 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 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: SB 277 Page 3 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. 1)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 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 (described in #4 of existing law above) from the existing immunization requirement for children in child care and public and private schools. Deletes related law requiring a form (described in #5 of existing law above) to accompany a personal belief exemption (PBE). 2)Exempts home-based private schools or students enrolled in an independent study program from the existing immunization requirement. SB 277 Page 4 3)Permits DPH to add diseases to the immunization requirements (described in #2 of existing law above) only if exemptions are allowed for both medical reasons and personal beliefs. 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 PBEs 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. 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 SB 277 Page 5 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 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 SB 277 Page 6 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 U.S. 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 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 SB 277 Page 7 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 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 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 SB 277 Page 8 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. Prior Legislation AB 2109 (Pan, Chapter 821, Statutes of 2012) required, 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. Required the form to include: 1)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. 2)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 to 1) 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, 2012) would have required a health care service plan or health insurer that provides coverage for SB 277 Page 9 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) alloweda 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) allowed DPH to update vaccination requirements for children entering schools and child care facilities and added 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, 2009) would have required a health care service plan or health insurer that provides coverage for childhood and adolescent immunizations to reimburse a physician or physician group the entire cost of acquiring and administering the vaccine, and would have prohibited 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, 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, 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, 2007) would have required pupils entering the seventh grade to be fully immunized against pertussis. SB SB 277 Page 10 676 was held on the Assembly Appropriations Committee suspense file. SB 533 (Yee, 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. FISCAL EFFECT: Appropriation: No Fiscal Com.:NoLocal: No SUPPORT: (Verified5/12/15) Vaccinate California (source) Insurance Commissioner Dave Jones AIDS Healthcare Foundation American Academy of Pediatrics American Federation of State, County and Municipal Employees American Lung Association American Nurses Association Association of Northern California Oncologists Biocom California Academy of Family Physicians California Academy of Physician Assistants California Association of Nurse Practitioners California Association of Physician Groups California Chapter of the American College of Emergency Physicians California Children's Hospital Association California Coverage and Health Initiatives California Disability Rights, Inc. California HealthCare Institute California Hepatitis Alliance California Hospital Association California Immunization Coalition California Medical Association California Optometric Association California Pharmacists Association California Primary Care Association SB 277 Page 11 California Public Health Association-North California School Boards Association California School Employees Association California School Nurses Organization California State Association of Counties California State Parent-Teacher Association Carlsbad High School Parent-Teacher-Student Association Child Care Law Center Children Now Children's Defense Fund California Children's Healthcare Is a Legal Duty, Inc. Children's Hospital Oakland Children's Specialty Care Coalition City and County of San Francisco City of Berkeley City of Beverly Hills City of Pasadena County Health Executives Association of California County of Alameda County of Los Angeles County of Marin County of Santa Clara County of Santa Cruz County of Santa Cruz Democratic Party County of Yolo Democratic Women's Club of Santa Cruz County First 5 California Foundation for Pediatric Health Health Officers Association of California Junior Leagues of California Kaiser Permanente Los Angeles Community College District Los Angeles County Supervisor Sheila Kuehl Los Angeles Unified School District March of Dimes California Chapter MemorialCare Health System Physician Society National Coalition of 100 Black Women Sacramento Chapter Osteopathic Physicians and Surgeons of California Project Inform Providence Health and Services Southern California San Dieguito Union High School District San Francisco Unified School District Santa Monica Malibu Union Unified School District Secular Coalition for California SB 277 Page 12 Silicon Valley Leadership Group Solano Beach School District The Children's Partnership UAW Local 5810, Postdoctoral Researchers at the University of California Hundreds of individuals OPPOSITION: (Verified5/12/15) AWAKE California Association of American Physicians and Surgeons California Chiropractic Association California Naturopathic Doctors AssociationCalifornia 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 Prepared by:Melanie Moreno / HEALTH / 5/13/15 16:37:45 **** END ****