BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                     SB 277


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          SENATE THIRD READING


          SB  
          277 (Pan and Allen)


          As Amended  June 18, 2015


          Majority vote


          SENATE VOTE:  25-11


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          |Committee       |Votes|Ayes                   |Noes                 |
          |                |     |                       |                     |
          |                |     |                       |                     |
          |                |     |                       |                     |
          |----------------+-----+-----------------------+---------------------|
          |Health          |12-6 |Bonta, Bonilla, Chiu,  |Maienschein, Chávez, |
          |                |     |Gomez, Gonzalez, Roger |Lackey, Patterson,   |
          |                |     |Hernández, Nazarian,   |Steinorth, Waldron   |
          |                |     |Ridley-Thomas,         |                     |
          |                |     |Rodriguez, Santiago,   |                     |
          |                |     |Thurmond, Wood         |                     |
          |                |     |                       |                     |
          |                |     |                       |                     |
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          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:   










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          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)Allows pupils who, prior to January 1, 2016, have a letter or  
            affidavit on file at a private or public elementary or  
            secondary school, child day care center, day nursery, nursery  
            school, family day care home, or development center stating  
            beliefs opposed to immunization, to continue enrollment until  
            the pupil enrolls in the next grade span, as defined.  Defines  
            grade span as birth to preschool, kindergarten to grade 6, and  
            grades 7 to 12. 


          3)Exempts students enrolled in home-based private schools or in  
            an independent study program that is not classroom-based from  
            the existing immunization requirement.


          4)Specifies that a pupil who qualifies for an individualized  
            education program, pursuant to specified laws, must have  
            access to any special education and related services required  
            by his or her individualized education program.


          5)Clarifies that a student is exempt from vaccination  
            requirements if a written statement by a licensed physician is  
            obtained 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, including, but not limited to,  
            family medical history, which the physician does not recommend  
            immunization.










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          6)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  








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            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,  
            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  
               indicating 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 to a) above.  


          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  








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            diseases, until the local health officer is satisfied that the  
            child is no longer at risk of developing the disease.


          FISCAL EFFECT:  None


          COMMENTS:  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.


          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 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.  








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          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 United States (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, 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 18 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  








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          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 majority of parents still  
          had questions or concerns about vaccines.  


          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.  


          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, while public health officials and  
          policy makers consider the benefits of vaccination to society  
          at-large.  As part of their research, the authors compared  
          childhood immunization rates and rates of vaccine-preventable  








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          childhood diseases before and after the introduction of school  
          vaccination requirements.  


          Current state law mandates immunization of school-aged 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.  The 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), 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].









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


           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.


          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 vaccinated in a population,  
          the lower the likelihood that a susceptible (unvaccinated)  
          person will physically come into contact with the infection.  It  








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          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% to 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  
          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  








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          students, or a high proportion of students receiving free or  
          reduced lunch, were more likely to have high vaccination rates  
          (less PBEs).  


          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:


          1)Forty-two cases visited Disneyland during December 17-20, 2014  
            where they are presumed to have been exposed to measles;


          2)Thirty-one are household or close contacts to a confirmed  
            case;










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


          4)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;


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


          6)Among measles cases for whom DPH has vaccination  
            documentation, 57 were unvaccinated and 25 had one 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.


          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.  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.  










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          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.  


          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  








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          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.


          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 levels  
          children's exposure to mercury in the vaccine preservative  
          thimerosal.  However, autism diagnosis continued to rise even  
          after thimerosal was removed from U.S. 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. 


          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.  


          1)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  








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            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.  


          2)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).   



          3)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  








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            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.   


          Special education.  Pursuant to the federal Individuals with  
          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.








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          Independent study.  April 22, 2015, amendments to this bill  
          exclude pupils who are enrolled in an independent study program  
          from the immunization requirements of this 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.  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:


          1)School-within-a-school;


          2)District or county alternative in a community location;


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


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


          5)District dropout prevention centers at selected community  
            sites;


          6)Curricular enrichment options offered to high school students  
            with special abilities and interests, scheduling problems, or  








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            individual needs that cannot be met in the regular program;


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


          8)Some combination of the above.


          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 should 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.


          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 12 were  
          enrolled in independent study.  


          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 in  
          many ways, such as requiring school attendance and regulating or  








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          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.


          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 15 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 co-sponsor of this bill,  
          states that efforts to contain the 2014 measles outbreak  
          resulted in unnecessary mandatory quarantines and the  
          redirection of public health resources to investigations into  
          exposure.  The California Immunization Coalition, writing in  
          support of this 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.  










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


          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.  









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          The Assembly Health 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  
          this bill removes federally mandated rights of services to  
          students with disabilities under the federal IDEA.  This group,  
          like many others, points to the National Vaccine Information  
          Center (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  
          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."









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          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 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.  


          Related legislation.  SB 792 (Mendoza) of the current  
          legislative session, 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.  


          Previous legislation.  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  








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          to include:


          1)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 communicable  
            diseases listed above to the person and to the community.


          2)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 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.




          Analysis Prepared by:                                             
                          Dharia McGrew and Paula Villescaz / HEALTH /  
          (916) 319-2097    FN: 0000953















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