BILL ANALYSIS                                                                                                                                                                                                    



                                                                     SB 277


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           Date of Hearing:  June 9, 2015


                            ASSEMBLY COMMITTEE ON HEALTH


                                  Rob Bonta, Chair


          SB  
          277 (Pan and Allen) - As Amended May 7, 2015


          SENATE VOTE:  25-11


          SUBJECT:  Public health: vaccinations.


          SUMMARY:  Eliminates non-medical exemptions 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.  Specifically, this bill:   






          1)Deletes the exemption based on personal beliefs from the  
            existing immunization requirement for children in child care  
            and public and private schools.  Deletes related law requiring  
            a form to accompany a personal belief exemption (PBE).



          2)Exempts students enrolled in home-based private schools or in  
            an independent study program from the existing immunization  
            requirement.








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          3)Permits the California Department of Public Health (DPH) to  
            add diseases to the immunization requirements only if  
            exemptions are allowed for both medical reasons and personal  
            beliefs.


          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 meningitis), measles, mumps, pertussis (whooping cough),  
            poliomyelitis, rubella (German measles), tetanus, hepatitis B,  
            and varicella (chickenpox).



          2)Permits 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 Committee on Infectious Diseases.



          3)Waives immunization requirements in 1) above, 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.







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          4)Waives the above immunization requirements if the parent,  
            guardian, or 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, guardian, or emancipated  
               minor, was provided with information regarding the benefits  
               and risks of the immunization and the health risks of the  
               specified diseases 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, guardian, or  
               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.










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          6)Permits a local health officer to temporarily exclude from the  
            school or institution 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, until the local health officer is satisfied that the  
            child is no longer at risk of developing the disease.


          FISCAL EFFECT:  None.  


          COMMENTS:


          1)PURPOSE OF THIS BILL.   According to the author, in early  
            2015, California became the epicenter of a measles outbreak,  
            which spread in large part because of communities with large  
            numbers of unvaccinated people.  According to the CDC, there  
            have been more cases of measles in January 2015 than in any  
            one month in the past 20 years.  Between 2000 and 2012, the  
            number of PBEs 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, by 2013, that number rose to 3.15%.  In certain  
            geographic pockets of California, exemption rates are 21% or  
            more, placing our communities at risk for the rapid spread of  
            entirely preventable diseases, according to the author.  Given  
            the highly contagious nature of diseases such as measles,  
            vaccination rates of up to 95% are necessary to protect the  
            public health of the community and prevent future outbreaks.



          2)BACKGROUND.   The diseases that vaccines prevent can be  
            dangerous, or even deadly.  According to the CDC, vaccines  
            reduce the risk of infection by working with the body's  
            natural defenses to help it safely develop immunity to  
            disease.  When bacteria or viruses invade the body, they  
            attack and multiply, creating an infection.  The immune system  
            then has to fight the illness.  Once it fights off the  







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            infection, the body is left with a supply of cells that help  
            recognize and fight that disease in the future.  Vaccines  
            contain the same antigens or parts of antigens that cause  
            diseases, but the antigens in vaccines are either killed or  
            greatly weakened.  This exposure to the antigens teaches the  
            immune system to develop the same response as it does to the  
            real infection so the body can recognize and fight the disease  
            in the future.  
          


            Public health experts agree that vaccines represent one of the  
            greatest achievements of science and medicine in the battle  
            against disease.  Vaccines are responsible for the control of  
            many infectious diseases that were once common around the  
            world, including polio, measles, diphtheria, pertussis,  
            rubella, mumps, tetanus, and Hib meningitis.  Vaccine helped  
            to eradicate 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.  





            In the U.S., the high vaccination rate for routinely  
            recommended immunizations for infant and childhood diseases  
            has brought about dramatic declines in the incidence of polio,  







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            measles, mumps, rubella, Haemophilus influenza type b,  
            hepatitis, and chickenpox.  In the past decade,  
            recommendations for annual influenza vaccination have been  
            expanded to encompass all children six months to eighteen  
            years of age, and new vaccines have been added to the  
            immunization schedule to help protect infants from rotavirus  
            disease and adolescents from meningitis.  As a result of the  
            advances in developing vaccines and including them as standard  
            of care, most diseases that are preventable by vaccination are  
            at record low levels in the U.S. 





            For years many of these diseases were thought to be ordinary  
            childhood experiences and many older adults had these diseases  
            as children.  Nevertheless, they are serious deadly diseases  
            for some.  For example, measles in children has a mortality  
            rate as high as about one in 500 among healthy children,  
            higher if there are complicating health factors.  


          


            In the past couple of decades, controversy has arisen about  
            vaccines and autism, the best number of injections to be  
            administered during a single visit or over the course of the  
            first years of life, and vaccine ingredients which has  
            prompted parents, the media, policy makers, and others to  
            raise concerns about the safety of recommended immunizations  
            as well as the vaccination schedule.  Despite their positive  
            impact on health and well-being, vaccines have had a long  
            history of arousing anxiety.  The rapid growth of the Internet  
            and social media has made it easier to find and disseminate  
            immunization-related concerns and misperceptions.  According  
            to a 2011 study published in the journal Health Affairs,  
            results indicate that although the overwhelming majority of  
            parents surveyed intended to vaccinate their children fully, a  







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            majority of parents still had questions or concerns about  
            vaccines.  


          3)School IMMUNIZATION 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 2001-02 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


            Current state law mandates immunization of school-aged  







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            children against 10 specific diseases.  Each of the 10  
            diseases was added to California code through legislative  
            action, after careful consideration of the public health risks  
            of these diseases, cost to the state and health system,  
            communicability, and rates of transmission.  The Legislature  
            has a long history of thoughtful consideration for which  
            diseases pose the most serious health risks to the public.   
            Following is a brief summary of activity related to mandated  
            immunizations for children enrolling in school:


              1889:   School districts first allowed to exclude a student  
                  who is not vaccinated against smallpox, and schools were  
                  required to maintain a list of unvaccinated children (SB  
                  92, Briceland, Chapter 24). 


              1961:   Polio immunization added as a requirement, as well  
                  as the first appearance of a philosophical exemption (AB  
                  1940, DeLotto and Rumford, Chapter 837). 


              1977:   Diphtheria, pertussis, tetanus, and measles were  
                  added to immunization requirements for children entering  
                  school (SB 942, Rains, Chapter 1176).  


              1979:   Mumps and rubella were added to the list (AB 805,  
                  Mangers, Chapter 435).  


              1992:   Haemophilus influenzae type b was added (AB 2798,  
                  Floyd, Chapter 1300, and AB 2294, Alpert, Chapter   
                  1320).  


              1995 and 1997: Hepatitis B was added (AB 1194, Takasugi,  
                  Chapter 291, Statutes of 1995 and AB 381, Takasugi,  
                  Chapter 882, Statutes of 1997). 








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              1999:   The Legislature voted to add Hepatitis A to the  
                  list, but it was vetoed by Governor Davis (AB 1594,  
                  Florez).


              1999:   Varicella was added to the list (SB 741, Alpert,  
                  Chapter 747).  


              2007:   The Legislature voted to add pneumococcus to the  
                  list, but it was vetoed by Governor Schwarzenegger (SB  
                  533, Yee).


              2010:   Tetanus, diphtheria and pertussis (TDaP) booster was  
                  required for 7th graders (AB 354, Arambula, Chapter  
                  434).  





            All of the diseases for which California requires school  
            vaccinations are very serious conditions that pose very real  
            health risks to children.  Most of the diseases can be spread  
            by contact with other infected children.  Tetanus does not  
            spread from student to student but because it is such a  
            serious potentially fatal disease, and it is easily  
            preventable by vaccine, the vaccination of children is  
            required prior to enrollment in school.





          4)COMMUNITY IMMUNITY.  Herd immunity occurs when a significant  
            proportion of the population (or the herd) has been  
            vaccinated, and this provides protection for unprotected  
            individuals.  The larger the number of people who are  







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            vaccinated in a population, the lower the likelihood that a  
            susceptible (unvaccinated) person will physically come into  
            contact with the infection.  It is more difficult for diseases  
            to spread between individuals if large numbers of people are  
            already immune, and the chain of infection is broken.  The  
            reduction of herd immunity places unvaccinated persons at  
            risk, including those who cannot receive vaccinations for  
            medical reasons.  Those who cannot receive vaccines include  
            those with compromised immune systems, older adults, small  
            children and babies, all depending on the vaccine.
            There the protective effect of herd immunity wanes as large  
            numbers of children do not receive some or all of the required  
            vaccinations, resulting in the reemergence of vaccine  
            preventable diseases in the U.S.  Statewide statistics  
            indicate that in 2014-15 school year, 90.4% of kindergartens  
            received all required immunizations.  The widespread reporting  
            of statewide numbers, however, potentially mask a better  
            understanding of more relevant data, such as town, city, or  
            county vaccination rates.  Because students are not  
            interacting with every individual in the entire state, the  
            local vaccination rate is more relevant to the discussion of  
            community immunity.



            The vaccination rate in various communities varies widely  
            across the state.  Those areas become more susceptible to an  
            outbreak than the state's overall vaccination levels may  
            suggest.  These communities make it difficult to control the  
            spread of disease and make us vulnerable to having the virus  
            re-establish itself. 


            Studies find that when belief exemptions to vaccination  
            guidelines are permitted, vaccination rates decrease.  An  
            analysis by the New York Times found that more than a quarter  
            of schools in California have measles-immunization rates below  
            the 92-94% recommended by the CDC.  Research shows that people  
            with lower vaccine acceptance tend to group together in  
            communities.  A study recently published in the journal  







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            Pediatrics found that schools with high PBE rates are  
            clustered in suburbs in the peripheral areas of California  
            cities.  The same analysis found that schools with low  
            proportion of white students, or a high proportion of students  
            receiving free or reduced lunch, were more likely to have high  
            vaccination rates (less PBEs).  


          5)California measles outbreak.  The authors point to an outbreak  
            of measles linked to Disneyland in in December 2014 as one of  
            the reasons for the introduction of this bill.  This outbreak  
            led to 131 confirmed measles cases reported in California as  
            part of this outbreak.  The outbreak, now declared over by  
            DPH, led to 19% of those infected requiring hospitalization.   
            The outbreak likely started from a traveler who became  
            infected overseas with measles, then visited the amusement  
            park while infectious; however, no source was identified.   
            Analysis by CDC scientists showed that the measles virus type  
            in this outbreak (B3) was identical to the virus type that  
            caused the large measles outbreak in the Philippines in 2014.



            According to the CDC, measles is one of the first diseases to  
            reappear when vaccination coverage rates fall.  In 2014, there  
            were over 600 cases reported to the CDC, the highest in many  
            years.  Between 2000 and 2007, the average number of cases was  
            63 per year, less than half the number of the Disney outbreak,  
            which is one of five outbreaks so far this year reported by  
            the CDC.







            Of the confirmed cases, DPH reported:









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                     Forty-two cases visited Disneyland during December  
                 17-20, 2014 where they are presumed to have been exposed  
                 to measles;
                     Thirty-one are household or close contacts to a  
                 confirmed case;


                     Fourteen were exposed in a community setting (e.g.,  
                 emergency room) where a confirmed case was known to be  
                 present;


                     Forty-four have unknown exposure source but are  
                 presumed to be linked to the outbreak based on a  
                 combination of descriptive epidemiology or strain type;


                     Five cases are known to have a different genotype  
                 from the outbreak strain; and,


                     Among measles cases for whom DPH has vaccination  
                 documentation, 57 were unvaccinated and 25 had 1 or more  
                 doses of measles, mumps, and rubella (MMR) vaccine.  A  
                 number of those unvaccinated had a personal belief  
                 exemption and also include many infants too young to be  
                 vaccinated.





          1)National Childhood Vaccine Injury Act.  During the mid-1970s,  
            there was an increased focus on personal health and more  
            people became concerned about vaccine safety.  Several  
            lawsuits were filed against vaccine manufacturers and  
            healthcare providers by people who believed they had been  
            injured by the TDaP vaccine.  Damages were awarded despite the  
            lack of scientific evidence to support vaccine injury claims.   







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            In 1976, a preemptive attempt to conduct a nationwide  
            influenza vaccination campaign for the swine flu stoked  
            peoples' fears.  The predicted epidemic did not occur and  
            there were some who argued this particular influenza vaccine  
            resulted in serious side effects.



            As a result, potential liability costs and vaccine prices  
            soared, and several vaccine manufacturers halted production.   
            A vaccine shortage resulted and public health officials became  
            concerned about the return of epidemic disease.  





            To reduce liability and respond to public health concerns,  
            Congress passed the National Childhood Vaccine Injury Act  
            (NCVIA) in 1986.  The NCVIA established the National Vaccine  
            Program Office (NVPO) to coordinate immunization related  
            activities among various federal agencies and requires health  
            care providers who give vaccines to provide an information  
            statement to the patient or guardian that contains a brief  
            description of the disease as well as the risks and benefits  
            of the vaccine.  Additionally, the NCVIA requires health care  
            providers to report certain adverse health events following  
            vaccination to the Vaccine Adverse Event Reporting System  
            (VAERS).  The VAERS system remains an important source of  
            information for the CDC and others to monitor the vaccine  
            program, but the system allows self-reporting by any citizen  
            or healthcare provider what they believe to be an adverse  
            vaccine-related event, but the event numbers publicly  
            available have not necessarily been medically verified or  
            scientifically studied.  The National Vaccine Injury  
            Compensation Program (NVICP) was created to compensate those  
                                                             injured by vaccines on a "no fault" basis.  The NVICP has been  
            loudly criticized by some for inefficient operations, and for  
            providing legal immunity to the pharmaceutical industry.  








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            The NCVIA established a committee from the Institute of  
            Medicine (IOM) to review the literature on vaccine reactions.   
            This group concluded that there are limitations in our  
            knowledge of the risks associated with vaccines.  The group  
            looked at 76 health problems to see if they were caused by  
            vaccines.  Of those, 50 (66%) had no or inadequate research to  
            form a conclusion.  The IOM identified several specific  
            problems, such as a limited understanding of biological  
            processes that underlie adverse events, incomplete and  
            inconsistent information from individual reports, poorly  
            constructed research studies (not enough people enrolled for  
            the period of time), inadequate systems to track vaccine side  
            effects, and few experimental studies were published in the  
            medical literature.  The CDC states that in the time since the  
            publication of the IOM reports in the 1990s, significant  
            progress has been made to monitor side effects and conduct  
            research relevant to vaccine safety.  In 2011 the IOM  
            published Adverse Effects of Vaccines: Evidence and Causality,  
            representing an extensive study of peer-reviewed vaccine  
            related research to date.  The IOM Committee reviewed eight  
            vaccines given to children or adults (MMR, varicella,  
            influenza, hepatitis A, hepatitis B, human papillomavirus,  
            meningococcal, and DTP) and again found that vaccines are  
            generally very safe and that serious adverse events are quite  
            rare.


          


          2)VACCINES AND AUTISM.   The idea that autism is caused by  
            vaccination is influencing public policy, even though rigorous  
            studies do not support this hypothesis.  The hypothesis is  
            based on the observation that the number of autism cases  
            increased in the 1980s, coinciding with a push for greater  
            childhood vaccinations, which increased above recommended  







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            levels children's exposure to mercury in the vaccine  
            preservative thimerosal.  However, autism diagnosis continued  
            to rise even after thimerosal was removed from US childhood  
            vaccines in 2001.  A review by the IOM of over 200 studies  
            concluded that that there was no causal link between  
            thimerosal-containing vaccines and autism.  Other studies have  
            found that autism is no more common among vaccinated than  
            unvaccinated children. 


          3)Exemptions to vaccine requirements.   There are currently  
            three types of exemptions to the requirement that children be  
            vaccinated before entering school:  medical; religious; and,  
            philosophical.  


             a)   A medical exemption letter can be written by a licensed  
               physician that believes that vaccination is not safe for  
               the medical conditions of the patient, such as those whose  
               immune systems are compromised, who are allergic to  
               vaccines, are ill at the time of vaccination, or have other  
               medical contraindications to vaccines for that individual  
               patient.  Every state allows medical exemptions from school  
               vaccination requirements.  This determination is entirely  
               up to the professional clinical judgment of the physician.   
               There are no required medical criteria for diagnosing  
               circumstances that contraindicate vaccination.  A physician  
               must base that decision on their professional judgment and  
               the standard of practice for their field.  According to the  
               Medical Board of California, the "standard of care" (or  
               "standard of practice") for general practitioners is  
               defined as that level of skill, knowledge and care in  
               diagnosis and treatment ordinarily possessed and exercised  
               by other reasonably careful and prudent physicians in the  
               same or similar circumstances at the time in question.   
               Specialists are held to the standard of skill, knowledge  
               and care ordinarily possessed and exercised by other  
               reasonably careful and prudent specialist in the same or  
               similar circumstances.  








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             b)   Religious exemptions allow parents to exempt their  
               children from vaccination if it contradicts their sincere  
               religious beliefs.  Many states allow religious exemptions  
               from school vaccination requirements, although states  
               interpret the enforcement of them differently.  In some  
               states, a parent may simply attest that vaccinations are  
               against their religious beliefs, while in other states the  
               parent must show membership in a church, and that the  
               church's official policy is opposed to vaccination.   
               According to the National Conference of State Legislatures  
               (NCSL), as of June 2014, 48 states allow religious  
               exemptions (all but Mississippi and West Virginia).  


             c)   Philosophical exemption, which is defined differently in  
               different states, generally 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 NCSL, 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.  The bills were tabled in Oregon and Washington.   
            On May 25, 2015, the Governor of Vermont signed legislation  
            removing philosophical exemptions, but not religious ones, in  
            that state.   


          4)SPECIAL EDUCATION.  Pursuant to the federal Individuals with  







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            Disabilities Education Act (IDEA), children with disabilities  
            are guaranteed the right to a free, appropriate public  
            education, including necessary services for a child to benefit  
            from his or her education.  Between 1976 and 1984, to meet  
            this federal mandate, California schools provided mental  
            health services to special education students who needed the  
            services pursuant to an Individualized Education Program  
            (IEP).  An IEP is a legally binding document that determines  
            what special education services a child will receive and why.   
            IEPs include a child's classification, placement, specialized  
            services, academic and behavioral goals, a behavior plan if  
            needed, percentage of time in regular education, and progress  
            reports from teachers and therapists.  A child may require any  
            related services in order to benefit from special education,  
            including (but not limited to): speech-language pathology and  
            audiology services, early identification and assessment of  
            disabilities in children, medical services, physical and  
            occupational therapy, orientation and mobility services; and  
            psychological services.  


            According to the California Department of Education (CDE),  
            over 700,000, or approximately 11% of, California students  
            received Special Education services in the 2013-14 academic  
            year.





          5)Independent Study.  April 22, 2015 amendments to this bill  
            exclude pupils who are enrolled in an independent study  
            program from the immunization requirements of the bill.   
            Independent study is an optional educational alternative,  
            available to students from kindergarten through high school  
            that is meant to respond to the student's specific educational  
            needs, interests, aptitudes, and abilities.  Independent study  
            is an alternative to classroom instruction consistent with a  
            school district's regular course of study and is expected to  
            be equal or superior in quality to classroom instruction.   







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            Each school district can develop Independent Study options in  
            its own way.  Parents and students may also develop  
            alternative forms of independent study and propose them to the  
            school board.  The options are based on the kinds of students  
            being served.  The following are some of the ways in which  
            independent study is organized:



             a)   School-within-a-school;
             b)   District or county alternative in a community location;


             c)   School-based independent study offered part-time and  
               full-time;


             d)   Countywide home-based independent study offered by the  
               county superintendent of schools;


             e)   District dropout prevention centers at selected  
               community sites;


             f)   Curricular enrichment options offered to high school  
               students with special abilities and interests, scheduling  
               problems, or individual needs that cannot be met in the  
               regular program;


             g)   Alternative school-based independent study, on-or  
               off-site; and,


             h)   Some combination of the above.











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            Independent study can be operated on a traditional school  
            calendar, with a summer school option for eligible students,  
            or on a year-round calendar within a year-round school.   
            Students must have the option of a classroom setting for a  
            full program at the time independent study is made available.   
            This option must be continuously available the student decide  
            to transfer from independent study.  The classroom setting  
            option can be offered by the county office of education if the  
            district and county have a formal agreement that has the  
            effect of providing the student with a program that is  
            equivalent to what is offered in the school of residence.





             a)   Seat Time / Average Daily Attendance.  Participation in  
               independent study must be voluntary.  For students  
               participating in independent study, a contractual agreement  
               is drawn among the certificated teacher, the student, and  
               his or her parent, guardian, or caregiver.  Attendance  
               records are based on a student's work within the terms and  
               conditions of his or her written agreement and not on  
               traditional "seat-time." In independent study, the  
               student's performance, measured by the terms in the  
               agreement, is converted by the supervising teacher into  
               school days.  The computed school days are reported as if  
               the student were physically in attendance.  
          


             b)   Legal Enrollment Restrictions.  California education law  
               mandates the following for the administration of  
               independent study programs:
          


               i)     No pupil shall be required to participate in  
                 independent study;







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               ii)    Not more than 10% of the students enrolled in an  
                 opportunity school or program, or a continuation high  
                 school, shall be eligible for independent study.  A  
                 student who is pregnant or is a parent and primary  
                 caregiver for one or more of his or her children shall  
                 not be counted within the 10% cap;


               iii)   No individual with exceptional needs may participate  
                 in independent study unless his or her IEP specifically  
                 provides for that participation; and,


               iv)    No temporarily disabled pupil may receive individual  
                 instruction.  However, if the temporarily disabled  
                 pupil's parents and the district(s) agree, the pupil may  
                 receive instruction through independent study instead of  
                 the "home and hospital" instruction.





             c)   Enrollment History.  According to CDE, in 2013-14 there  
               were approximately 122,000 independent study students  
               reported by charter schools and 34,000 reported by school  
               districts.  Independent study enrollment was not collected  
               for the 2009-10 and 2010-11 school years.  In October 2008,  
               data collected from schools reported that 128,000 students  
               in kindergarten through grade twelve were enrolled in  
               independent study.  



          6)Legal Considerations.  Courts have determined that the family  
            itself is not beyond regulation in the public interest and  
            neither rights of religion nor rights of parenthood are beyond  
            limitation.  As discussed at length in the Senate Judiciary  
            Committee analysis, extensive case law establishes that the  
            police powers of the state may restrict the parent's control  







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            in many ways, such as requiring school attendance and  
            regulating or prohibiting the child's labor.  This authority  
            is not nullified because the parent grounds his claim to  
            control the child's course of conduct on religion or  
            conscience.  Thus, a parent cannot claim freedom from  
            compulsory vaccination for their child more than for himself  
            on religious grounds.  The right to practice religion freely  
            does not include liberty to expose the community or the child  
            to communicable disease or the latter to ill health or death.   
            For a further discussion of the legal rights and ramifications  
            of this bill, please see the Senate Judiciary Committee  
            Analysis as published on April 28, 2015.


          7)SUPPORT.   The Superintendent of Public Instruction (SPI), Tom  
            Torlakson, supports this bill, stating that school and child  
            care immunization requirements have proven effective in  
            increasing immunization rates, limiting the spread of disease,  
            and providing an overall public health benefit.  He further  
            states that California has seen a dramatic increase in the PBE  
            rate for students entering kindergarten over the past fifteen  
            years, placing other children, and the overall public health  
            of our citizens, at risk of illness or death from preventable  
            diseases.  The SPI concludes that education is a fundamental  
            right in California, and this bill provides education choices  
            for families opting not to vaccinate their children.  





            The California Medical Association, a cosponsor of this bill,  
            states that in 2000, the CDC determined that measles had been  
            eradicated in the U.S.  However, since December 2014,  
            California has had 136 confirmed cases of measles across  
            fourteen counties.  Almost 20% of those cases have required  
            hospitalization.  Efforts to contain the outbreak have  
            resulted in mandatory quarantines and the redirection of  
            public health resources to investigations into exposure.  The  
            California Immunization Coalition, writing in support of this  







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            bill, notes that in the 2013-14 school year more than 16,800  
            kindergarteners in California started school with either no  
            vaccinations or only some of their required vaccinations  
            because their parent had chosen to exempt them from  
            vaccinations, representing a 25% increase over the previous  
            two school years.  





            March of Dimes Foundation and the Medical Oncology Association  
            of Southern California, Inc. state that public participation  
            in immunization programs is critical to their effectiveness.   
            Protection is greatly affected by rates of immunization:  the  
            more people immunized, the less the risk of exposure to, and  
            illness from, vaccine-preventable infections. 





            The Medical Board of California states that vaccines have been  
            scientifically proven to be effective in preventing illnesses.  
             Ensuring that children receive the ACIP recommended  
            vaccination schedule is the standard of care, unless there is  
            a medical reason that the child should not receive the  
            vaccine; this bill would still allow for a medical exemption  
            to address these concerns.  The Children's Specialty Care  
            Coalition notes that high vaccine coverage, particularly at  
            the community level, is extremely important for people who  
            cannot be vaccinated, including people who have medical  
            contraindications to vaccinations and those who are too young  
            to be vaccinated.  Protecting the individual and the community  
            from communicable diseases such as measles, mumps, and  
            pertussis, is important to the public's health.


            The Committee notes it has received hundreds of letters in  
            support of this bill.  Many letters from individuals in  







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            support write to raise similar points regarding reductions in  
            vaccination rates for school children, recent dangerous  
            measles and pertussis outbreaks, concerns for the health of  
            children and medically fragile individuals, and concerns for  
            the safety of communities at large. 


          8)OPPOSITION.  Opponents state that this bill is an extreme  
            measure that is not necessary at this time.  The California  
            Chiropractic Association states that this bill proffers the  
            notion that health officials will be given the power to  
            nullify the doctor-patient relationship, and veto the judgment  
            of any physician who questions the status quo and believes  
            that a patient should not receive a particular vaccine.  A  
            Voice for Choice states that the Legislature should look to  
            alternative approaches that will stop the transmission of  
            disease and continue to allow parents to work with their  
            doctors for the best vaccination schedule for their individual  
            children, and allow their children their constitutional right  
            to a free and public education.  


            The Committee also notes that it received hundreds of letters  
            in opposition to this bill.  A letter from Our Kids Our Choice  
            and many other similar letters argue that the bill removes  
            federally mandated rights of services to students with  
            disabilities under the federal IDEA.  This group, like many  
            others, points to the NVIC and the fact that the U.S.  
            government "has paid out more than $3 billion to the victims  
            of vaccine injury" as support for why medical choice is  
            appropriate.  "If there is risk of injury or death there must  
            be a choice."  In contrast, they argue that "vaccination rates  
            of California schoolchildren are high at 98.64%" and cite the  
            success of recent legislation, AB 2109 (Pan), Chapter 821,  
            Statutes of 2012, which they say has resulted in a 19%  
            decrease in exemptions amongst kindergarteners in just one  
            year.  They argue the public health concerns are already  
            adequately addressed with current California laws.  Many  
            letters from individuals write to raise relatively similar  
            points regarding various constitutional rights, informed  







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            consent, vaccine safety/injuries, absence of a health crisis,  
            lack of educational choice, difficulty in obtaining medical  
            exemptions, and the like.  


            ParentalRights.Org states that "?while we appreciate the  
            intent of the amendment to exempt homeschoolers from the  
            vaccination requirement, it is not sufficient to protect the  
            rights of parents and children in California.  While there are  
            many parents with strong convictions that the risks of  
            vaccines to their child (as reflected in lengthy disclaimers  
            which accompany these products) outweigh the potential  
            benefits, many of these same parents are also deeply convinced  
            that the best educational opportunity they can provide their  
            child is in the public schools.  These parents should not be  
            forced to give up their rights in one area to exercise their  
            rights in another.  No child should have to forego the best  
            available education for the sake of his best health, nor give  
            up his best health for the sake of a better education."


          9)CONCERNS.  American Civil Liberties Union of California  
            (ACLU-CA) states that "while we appreciate that vaccination  
            against childhood diseases is a prudent step that should be  
            promoted for the general welfare, we 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 for every school  
            district in the state."  ACLU-CA further states that unlike  
            other states where a vaccination mandate may be more  
            permissible, public education is a fundamental right under the  
            California Constitution.  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 California Association of  
            Private School Organizations states that that association has  
            taken no formal position on the measure, and does not oppose  
            the elimination of the PBEs, they are concerned about the  
            increased administrative burden to which schools will be  
            subjected should this bill become law.  The association urges  







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            amendments that would create a phase-in period, lengthen the  
            time horizon for compliance as per the existing regulations,  
            or enact such other provisions as may produce a combination of  
            increased compliance and a decreased possibility of mandatory  
                    exclusion.  


          10)RELATED LEGISLATION.  SB 792 (Mendoza) prohibits 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 was approved by the Senate on  
            May 22, 2015 by a vote of 34-3 and is currently pending  
            committee referral in the Assembly.  


          11)PREVIOUS LEGISLATION.   


             a)   AB 2109 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.   
               Required the form to include:

               i)     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.

               ii)    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  







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                 received the information provided by the health care  
                 practitioner pursuant to i) 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."



             b)   SB 614 (Kehoe, Chapter 123, Statutes of 2011) allows 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, if that pupil has not been fully  
               immunized with all pertussis boosters appropriate for the  
               pupil's age if specified conditions are met.

             c)   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 seven through 12 receive a TDaP  
               booster prior to admittance to school.



             d)   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  







                                                                     SB 277


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               Committee.



          12)POLICY COMMENTS.  


             a)   Collecting complete data will provide an accurate  
               picture of partial vaccination rates throughout the state.   
               To date, we do not have an exact picture of the vaccination  
               status of every student in California.  For the 2014-15  
               school year, less than 95% of schools reported their  
               vaccination numbers to DPH.  Of the schools reporting, DPH  
               found that 90.4% of enrolled kindergarteners had received  
               the complete vaccination schedule.  Additionally 6.9% of  
               students were conditionally enrolled because they were  
               lacking some immunizations, and were in the process of  
               completing the required vaccination schedule.  For the  
               2014-15 school year, DPH calculated individual antigen  
               vaccination status (such as DTP, Polio, MMR, etc) based  
               only on the number of fully vaccinated students and  
               vaccinations completed by conditionally enrolled students.   
               DPH did not include in this calculation the individual  
               antigen status for partially vaccinated students with PBEs.  
                Therefore, it is likely that individual antigen  
               immunization coverage may be underestimated.  Anecdotal  
               evidence suggests that some percentage of students have  
               some, but not all, required immunizations.  


               DPH is currently developing new regulations that will  
               implement complete data collection for partially vaccinated  
               students holding PBEs and medical exemptions.  This will  
               ensure that reported data are a more accurate reflection of  
               the vaccination rate for each immunization. 


             b)   Identification of partially and non-vaccinated students.  
                Current law requires that parents filing a PBE must  
               provide the school with documentation for "which  







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               immunizations have been given and which immunizations have  
               not been given on the basis that they are contrary to his  
               or her beliefs" for the purposes of immediate  
               identification in case of disease outbreak in the  
               community.  As drafted, this requirement would be deleted  
               by SB 277.  If SB 277 is enacted, schools will still need  
               to know which specific immunizations have or have not been  
               received by all students, including those that are enrolled  
               in independent study.  The author may wish to take an  
               amendment to clarify that schools will collect information  
               for all enrolled students, regardless of immunization  
               status.


          13)SUGGESTED AMENDMENTS.  


             a)   A physician's professional judgment.  As previously  
               discussed, it is entirely within the professional judgment  
               of a physician to determine if vaccination is not  
               recommended due to the medical history of the patient.   
               Opponents of this bill have raised concerns that current  
               law regarding the letter of medical exemption does not  
               adequately make clear that the letter may be written based  
               on the best medical judgment of the physician.  To that  
               end, the author may wish to consider amending this bill.
               


                 Section 120370.  (a)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  for which the physician does not recommend  
                 immunization, that child shall be exempt from the  
                 requirements of Chapter 1 (commencing with Section  
                 120325, but excluding Section 120380) and Sections  







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                 120400, 120405, 120410, and 120415 to the extent  
                 indicated by the physician's statement.





             b)   Implementation clarification clause.  As discussed in  
               the Senate Judiciary Committee analysis, clarification is  
               needed to address the status of students currently enrolled  
               with an existing PBE upon the operative date of this bill.   


                 Section 120335 (g) The governing authority shall allow  
                 continued enrollment to pupils who, prior to January 1,  
                 2016, have a letter or affidavit on file in that  
                 institution stating beliefs opposed to immunization.  On  
                 and after July 1, 2016, the governing authority shall not  
                 unconditionally admit to that institution for the first  
                 time or admit or advance any pupil to the 7th grade level  
                 unless the pupil has been immunized as required by this  
                 section.


             c)   Special education students must have access to services.  
                As previously discussed, under federal and state law  
               disabled children are guaranteed the right to a free,  
               appropriate public education, including necessary services  
               for a child to benefit from his or her education.  An  
               amendment should be taken to clarify that students with an  
               IEP will still have access to special education related  
               services as directed by their IEP. 


                 Section 120335 (h)  Nothing in this section shall  
                 prohibit a pupil that qualifies for an individualized  
                 education program, pursuant to federal law and Section  
                 56026 of the Education Code, from accessing any special  
                 education and related services required by their  
                 individualized education program. 







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             d)   Independent study programs are highly variable.  As  
               previously discussed, students enrolled in an independent  
               study program are excluded from the provisions of this bill  
               requiring them to be vaccinated.  Independent study courses  
               take many forms and in many places, including both on and  
               off school sites. As currently drafted, there is nothing  
               differentiating classroom based versus non-classroom based  
               independent study instruction.  An amendment should be  
               taken to specify that students enrolled in off-campus  
               independent study are not subject to vaccination  
               requirements. 


                 Section 120335 (f):This section does not apply to a pupil  
                 in a home-based private school or a pupil who is enrolled  
                 in an independent study program pursuant to Article 5.5  
                 (commencing with Section 51745) of Chapter 5 of Part 28  
                 of the Education Code and does not receive  
                 classroom-based instruction.


          REGISTERED SUPPORT / OPPOSITION:




          Support


















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                                                                    Page  31






          California Immunization Coalition (cosponsor)


          California Medical Association (cosponsor)


          Vaccinate California (cosponsor)


          Dave Jones, California Insurance Commissioner


          Katie Rice, Supervisor, Marin County


          Sheila Kuehl, Los Angeles County Supervisor and former State  
            Senator


          Tom Torlakson, California Superintendent of Public Instruction


          AIDS Healthcare Foundation


          Alameda County Board of Supervisors


          Albany Unified School District


          American Academy of Pediatrics - California


          American College of Emergency Physicians California Chapter










                                                                     SB 277


                                                                    Page  32







          American Federation of State, County and Municipal Employees,  
            AFL-CIO


          American Lung Association


          American Nurses Association\California


          Association of California School Administrators


          Association of Northern California Oncologists


          BIOCOM


          California Academy of Family Physicians


          California Academy of Physician Assistants


          California Association for Nurse Practitioners


          California Association of Physician Groups


          California Black Health Network












                                                                     SB 277


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          California Children's Hospital Association


          California Coverage and Health Initiatives


          California Department of Insurance


          California Disability Rights, Inc.


          California Healthcare Institute


          California Hepatitis Alliance


          California Hospital Association


          California Immunization Coalition


          California Optometric Association


          California Pharmacists Association


          California Primary Care Association


          California Public Health Association-North












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          California School Boards Association


          California School Employees Association


          California School Nurses Organization


          California State Association of Counties


          California State PTA


          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












                                                                     SB 277


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          City and County of San Francisco Board of Supervisors


          City of Berkeley


          City of Beverly Hills


          City of Pasadena


          Contra Costa County


          County Health Executives Association of California


          County of Marin


          County of Tehachapi


          Democratic Women's Club of Santa Cruz County


          Donate Life California


          First 5 California


          Foundation for Pediatric Health












                                                                     SB 277


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          Gilroy Unified School District


          Health Officers Association of California


          Jay Hansen, Sacramento County School Board Member


          Junior Leagues of California


          Kaiser Permanente


          Los Angeles Community College District


          Los Angeles County Board of Supervisors


          Los Angeles County Supervisor Sheila Kuehl


          Los Angeles Unified School District


          March of Dimes California Chapter


          Medical Board of California


          Medical Oncology Association of Southern California












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          MemorialCare Health System Physician Society


          National Coalition of 100 Black Women Sacramento Chapter


          Osteopathic Physicians and Surgeons of California


          Pasadena Public Health Department


          Project Inform


          Providence Health and Services, Southern California


          Reed Union School District


          San Dieguito Union High School District


          San Francisco Democratic County Central Committee


          San Francisco Unified School District


          Santa Clara County Board of Supervisors


          Santa Cruz County












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          Santa Cruz County Democratic Party


          Santa Monica Malibu Union Unified School District


          School for Integrated Academics and Technologies, California


          Secular Coalition for California


          Silicon Valley Leadership Group


          Solano Beach School District


          Sonoma County Board of Supervisors


          The Children's Partnership


          UAW Local 5810, University of California Postdoctoral  
            Researchers


          University of California Hastings College of the Law


          University of California, Irvine Center for Virus Research


          University of California, Irvine School of Medicine











                                                                     SB 277


                                                                    Page  39






          Yolo County Board of Supervisors


          Numerous Medical Doctors


          Numerous Osteopathic Doctors


          Numerous health care professionals, including RNs, PAs and NPs


          Hundreds of individuals
































                                                                     SB 277


                                                                    Page  40







          Opposition



          A Voice for Choice


          Alliance of California Autism Organizations


          Association of American Physicians and Surgeons (Tucson, AZ)


          APLUS+ Network Association


          Autism Society


          AWAKE California


          California Chiropractic Association


          California Coalition for Health Choice


          California Naturopathic Doctors Association


          California Nurses for Ethical Standards


          California Nurses for Ethical Standards










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          California ProLife Council


          California Right to Life Committee, Inc.


          Canary Party


          Capitol Resource Institute


          Educate.  Advocate.


          Educate. Advocate.


          Faith and Public Policy


          Families for Early Autism Treatment


          Foundation for Pediatric Health


          Gold Mine Natural Food Co.


          Homeschool Association of California


          HSC Homeschool Association of California


          National Autism Association California










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                                                                    Page  42





          National Vaccine Information Center


          Our Kids, Our Choice


          Pacific Justice Institute


          Pacific Justice Institute Center for Public Policy


          ParentalRights.Org


          Pediatric Alternatives


          SafeMinds


          Saint Andrew Orthodox Christian Church


          Standing Tall Chiropractic: A Creating Wellness Center


          Unblind My Mind


          Vaccine Choice Canada (Winlaw, British Columbia)


          Vaccine-Injury Awareness League


          Weston A. Price Foundation










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          Numerous Chiropractors


          Numerous Medical and Osteopathic Doctors


          Hundreds of individuals




          


          Analysis Prepared by:Dharia McGrew and Paula Villescaz / HEALTH  
          / (916) 319-2097