BILL ANALYSIS                                                                                                                                                                                                    Ó




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          |SENATE RULES COMMITTEE            |                        SB 277|
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                                UNFINISHED BUSINESS 


          Bill No:  SB 277
          Author:   Pan (D) and Allen (D), et al.
          Amended:  6/18/15  
          Vote:     21  

           SENATE HEALTH COMMITTEE:  6-2, 4/8/15
           AYES:  Nguyen, Hall, Mitchell, Monning, Pan, Wolk
           NOES:  Nielsen, Roth
           NO VOTE RECORDED:  Hernandez

           SENATE EDUCATION COMMITTEE:  7-2, 4/22/15
           AYES:  Liu, Block, Hancock, Mendoza, Monning, Pan, Vidak
           NOES:  Runner, Leyva

           SENATE JUDICIARY COMMITTEE:  5-1, 4/28/15
           AYES:  Jackson, Hertzberg, Leno, Monning, Wieckowski
           NOES:  Anderson
           NO VOTE RECORDED:  Moorlach

           SENATE FLOOR:  25-11, 5/14/15
           AYES:  Allen, Beall, Block, Cannella, De León, Galgiani, Hall,  
            Hancock, Hernandez, Hertzberg, Hill, Jackson, Lara, Leno, Liu,  
            McGuire, Mendoza, Mitchell, Monning, Pan, Pavley, Stone,  
            Vidak, Wieckowski, Wolk
           NOES:  Anderson, Bates, Fuller, Gaines, Huff, Leyva, Moorlach,  
            Morrell, Nielsen, Roth, Runner
           NO VOTE RECORDED:  Berryhill, Hueso, Nguyen

           ASSEMBLY FLOOR:  46-31, 6/25/15 - See last page for vote

           SUBJECT:   Public health: vaccinations


          SOURCE:    Vaccinate California









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          DIGEST:  This bill eliminates the personal belief exemption from  
          the requirement that children receive vaccines for certain  
          infectious diseases prior to being admitted to any public or  
          private elementary or secondary school or day care center.




          Assembly Amendments:




          1)Require a pupil who, prior to January 1, 2016, submitted 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 be allowed  
            enrollment to any private or public elementary or secondary  
            school, child day care center, day nursery, nursery school,  
            family day care home, or development center until the pupil  
            enrolls in the next grade span.




          2)Define "grade span" as: a) birth to preschool; b) kindergarten  
            (including transitional kindergarten) to grade 6; or c) grades  
            7 to 12.




          3)Prohibit a school's governing authority from otherwise  
            unconditionally admitting to any of those institutions  
            specified in #1 above for the first time, or admit or advance  
            any pupil to 7th grade level, unless the pupil has been  
            immunized for his or her age as required by this bill.











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          4)Specify that the above provisions do not prohibit a pupil who  
            qualifies for an individualized education program from  
            accessing any special education and related services required  
            by his or her individualized education program.




          5)Make other technical, clarifying amendments.


          ANALYSIS:   


          Existing law:


          1)Prohibits the governing authority of a school or other  
            institution from unconditionally admitting any person as a  
            pupil of any private or public elementary or secondary school,  
            child care center, day nursery, nursery school, family day  
            care home, or development center, unless, prior to his or her  
            first admission to that institution, he or she has been fully  
            immunized against diphtheria, haemophilus influenzae type b  
            (Hib), measles, mumps, pertussis, poliomyelitis, rubella,  
            tetanus, hepatitis b (except after 7th grade), and chickenpox,  
            as specified. 

          2)Permits the Department of Public Health (DPH) to add to this  
            list any other disease deemed appropriate, taking into  
            consideration the recommendations of the Centers for Disease  
            Control and Prevention (CDC) Advisory Committee on  
            Immunization Practices (ACIP) and the American Academy of  
            Pediatrics (AAP) Committee on Infectious Diseases.  

          3)Waives the above immunization requirements if the parent or  
            guardian files with the governing authority a written  
            statement by a licensed physician to the effect that the  
            physical condition of the child is such, or medical  
            circumstances relating to the child are such, that  
            immunization is not considered safe, indicating the specific  








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            nature and probable duration of the medical condition or  
            circumstances that contraindicate immunization.

          4)Waives the above immunization requirements if the parent or  
            guardian or adult who has assumed responsibility for the  
            child's care and custody, or the person seeking admission, if  
            an emancipated minor, files a letter with the governing  
            authority stating that the immunization is contrary to his or  
            her beliefs. 

          5)Requires a separate form prescribed by DPH to accompany a  
            letter or affidavit to exempt a child from immunization  
            requirements on the basis that an immunization is contrary to  
            beliefs of the child's parent or guardian.  Requires the form  
            to include:

             a)   A signed attestation from the health care practitioner  
               that indicates that the parent or guardian of the person  
               who is subject to the immunization requirements, the adult  
               who has assumed responsibility for the care and custody of  
               the person, or the person if an emancipated minor, was  
               provided with information regarding the benefits and risks  
               of the immunization and the health risks of the  
               communicable diseases listed above to the person and to the  
               community. Requires the attestation to be signed not more  
               than six months before the date when the person first  
               becomes subject to the immunization requirement for which  
               exemption is being sought.

             b)   A written statement signed by the parent or guardian of  
               the person who is subject to the immunization requirements,  
               the adult who has assumed responsibility for the care and  
               custody of the person, or the person if an emancipated  
               minor, that indicates that the signer has received the  
               information provided by the health care practitioner  
               pursuant a) above. Requires the statement to be signed not  
               more than six months before the date when the person first  
               becomes subject to the immunization requirements as a  
               condition of admittance.

          1)Permits a child for whom the requirement has been waived,  
            whenever there is good cause to believe that he or she has  








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            been exposed to one of the specified communicable diseases, to  
            be temporarily excluded from the school or institution until  
            the local health officer is satisfied that the child is no  
            longer at risk of developing the disease.


          This bill:


          1)Deletes the exemption for personal beliefs (described in #4 of  
            existing law above) from the existing immunization requirement  
            for children in child care and public and private schools.   
            Deletes related law requiring a form (described in #5 of  
            existing law above) to accompany a personal belief exemption  
            (PBE).  

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

          3)Permits DPH to add diseases to the immunization requirements  
            (described in #2 of existing law above) only if exemptions are  
            allowed for both medical reasons and personal beliefs.


          4)Requires a pupil who, prior to January 1, 2016, submitted 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 be allowed  
            enrollment to any private or public elementary or secondary  
            school, child day care center, day nursery, nursery school,  
            family day care home, or development center until the pupil  
            enrolls in the next grade span.




          5)Defines "grade span" as: a) birth to preschool; b)  
            kindergarten (including transitional kindergarten) to grade 6;  
            or c) grades 7 to 12.









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          6)Prohibits a school's governing authority from otherwise  
            unconditionally admitting to any of those institutions  
            specified in #4 above for the first time, or admit or advance  
            any pupil to 7th grade level, unless the pupil has been  
            immunized for his or her age as required by this bill.




          7)Specifies that the above provisions do not prohibit a pupil  
            who qualifies for an individualized education program from  
            accessing any special education and related services required  
            by his or her individualized education program.




          8)Makes other technical, clarifying amendments.


          Comments
          
          1)Author's statement.  According to the author, in early 2015,  
            California became the epicenter of a measles outbreak which  
            was the result of unvaccinated individuals infecting  
            vulnerable individuals including children who are unable to  
            receive vaccinations due to health conditions or age  
            requirements. According to the CDC, there were been more cases  
            of measles in January 2015 in the U.S. than in any one month  
            in the past 20 years. Measles has spread through California  
            and the U.S., in large part, because of communities with large  
            numbers of unvaccinated people. Between 2000 and 2012, the  
            number of PBEs from vaccinations required for school entry  
            that were filed rose by 337 percent. In 2000, the PBE rate for  
            kindergartners entering California schools was under one  
            percent. However, as of 2012, that number rose to 2.6 percent.  
            From 2012 to 2014, the number of children entering  
            kindergarten without receiving some or all of their required  
            vaccinations due to their parent's personal beliefs increased  








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            to 3.15 percent (a 25 percent increase over the previous two  
            years).  In certain pockets of California, exemption rates are  
            as high as 21 percent which places our communities at risk for  
            preventable diseases. Given the highly contagious nature of  
            diseases such as measles, vaccination rates of up to 95  
            percent are necessary to preserve herd immunity and prevent  
            future outbreaks.

          2)Immunizations.  According to the CDC, vaccines contain the  
            same antigens or parts of antigens that cause diseases, but  
            the antigens in vaccines are either killed or greatly  
            weakened. Vaccine antigens are not strong enough to cause  
            disease, but they are strong enough to make the immune system  
            produce antibodies against them. Memory cells prevent  
            re-infection when they encounter that disease again in the  
            future. Vaccines are responsible for the control of many  
            infectious diseases that were once common around the world,  
            including polio, measles, diphtheria, pertussis (whooping  
            cough), rubella (German measles), mumps, tetanus, and Hib.  
            Vaccine eradicated smallpox, one of the most devastating  
            diseases in history. Over the years, vaccines have prevented  
            countless cases of infectious diseases and saved literally  
            millions of lives. Vaccine-preventable diseases have a costly  
            impact, resulting in doctor's visits, hospitalizations, and  
            premature deaths. Sick children can also cause parents to lose  
            time from work. CDC recommends routine vaccination to prevent  
            17 vaccine-preventable diseases that occur in infants,  
            children, adolescents, or adults.

          3)ACIP. According to ACIP, it consists of 15 experts who are  
            voting members and are responsible for making vaccine  
            recommendations. The Secretary of the U.S. Department of  
            Health and Human Services selects these members after an  
            application, interview, and nomination process. Fourteen of  
            the members have expertise in vaccinology, immunology,  
            pediatrics, internal medicine, nursing, family medicine,  
            virology, public health, infectious diseases, and/or  
            preventive medicine; one member is a consumer representative  
            who provides perspectives on the social and community aspects  
            of vaccination. ACIP develops written recommendations for the  
            routine administration of vaccines to pediatric and adult  
            populations, along with schedules regarding the appropriate  








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            periodicity, dosage, and contraindications applicable to the  
            vaccines and is the only entity within the federal government  
            which makes such recommendations. The overall goals of ACIP  
            are to provide advice to assist in reducing the incidence of  
            vaccine-preventable diseases and to increase the safe usage of  
            vaccines and related biological products.  

            ACIP, along with AAP, the American Academy of Family  
            Physicians, and the American College of Obstetricians and  
            Gynecologists, approved the 2015 Recommended Immunization  
            Schedules for Persons Aged 0 Through 18 Years. Children under  
            six are recommended to receive vaccines for: hepatitis b;  
            rotavirus; diphtheria, tetanus, and pertussis (DTaP); Hib;  
            pneumococcal; polio; influenza; measles, mumps, rubella (MMR);  
            varicella; hepatitis a; and meningococcal.

          4)School vaccination requirements.  States enact laws or  
            regulations that require children to receive certain vaccines  
            before they enter childcare facilities and school, but with  
            some exceptions, including medical, religious, and  
            philosophical objections. School vaccination requirements are  
            thought to serve an important public health function, but can  
            also face resistance. An article published in the 2001-2002  
            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  








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            before and after the introduction of school vaccination  
            requirements. The data suggest that school vaccination  
            requirements have succeeded in increasing vaccination rates  
            and reducing the incidence of childhood disease.

          5)Exemptions to vaccine requirements.  There are two types of  
            non-medical exemptions to the requirement that children be  
            vaccinated before entering school: religious exemption and  
            philosophical exemption.  Religious exemption means that there  
            is a provision in the statute that allows parents to exempt  
            their children from vaccination if it contradicts their  
            sincere religious beliefs.  Philosophical exemption means that  
            the statutory language does not restrict the exemption to  
            purely religious or spiritual beliefs.  For example, Maine  
            allows restrictions based on "moral, philosophical or other  
            personal beliefs," and California allows objections based on  
            simply the parent(s) beliefs.  According to the National  
            Conference of State Legislatures, as of June 2014, 48 states  
            allow religious exemptions (all but Mississippi and West  
            Virginia), and 20 states (Arizona, California, Colorado,  
            Idaho, Louisiana, Maine, Michigan, Minnesota, Missouri  
            (limited to childcare enrollees), New Mexico, North Dakota,  
            Ohio, Oklahoma, Pennsylvania, Texas, Utah, Vermont,  
            Washington, West Virginia, and Wisconsin) permit philosophic  
            exemptions.  As of February, several state legislatures had  
            introduced bills that would address non-medical exemptions.  

          6)California vaccination rates.  According to an August 2014 DPH  
            fact sheet, vaccination coverage in California is at or near  
            all-time high levels. DPH states that the implementation of  
            current vaccine requirements has been effective in maintaining  
            greater than or equal to 92 percent immunization coverage  
            among children in licensed child care facilities and  
            kindergartens.  The DPH Immunization Branch maintains data on  
            its website related to vaccination rates and is searchable  
            statewide and by school (kindergarten and 7th grade rates) and  
            child care facility.  For school year 2014-15, DPH reported  
            that 90.4 percent of the 535,332 students enrolled in  
            reporting kindergartens received all required immunizations,  
            which is a 0.2 percent increase from last year. In addition,  
            the percentage of conditional entrants increased by 0.4  
            percent from last year. The percentage of students with  








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            permanent medical exemptions stayed the same at 0.19 percent,  
            and there was a 0.61 percent decrease in students with PBEs  
            compared with last year. Immunization coverage remained above  
            92 percent for each vaccine for all schools since last year.

          7)California measles outbreak.  The authors point to an outbreak  
            of measles that began in December 2014 in Disneyland (Orange  
            County) as one of the reasons for the introduction of this  
            bill. There were 134 confirmed measles cases reported in  
            California residents as part of this outbreak, which DPH now  
            considers over. Of the confirmed cases: 40 cases visited  
            Disneyland between December 17 and 20 where they are presumed  
            to have been exposed to measles; 30 are household or close  
            contacts to a confirmed case; 11 were exposed in a community  
            setting (e.g., emergency room) where a confirmed case was  
            known to be present; 50 have an unknown exposure source but  
            are presumed to be linked to the outbreak based on a  
            combination of descriptive epidemiology or strain type; and,  
            three cases are known to have a different genotype from the  
            outbreak strain. The ages of those infected with the measles  
            during this outbreak varied, with 56 percent being 20 years or  
            older, 18 percent were between the ages of five and 19, 15  
            percent were ages one to four, and 11 percent were under the  
            age of one. Among measles cases for whom DPH have vaccination  
            documentation, 57 were unvaccinated and 25 had one or more  
            doses of MMR vaccine.

          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:NoLocal:    No


          SUPPORT:   (Verified6/23/15)


          Vaccinate California (source)
          Insurance Commissioner Dave Jones
          AIDS Healthcare Foundation
          American Academy of Pediatrics
          American Federation of State, County and Municipal Employees
          American Lung Association
          American Nurses Association
          Association of Northern California Oncologists








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          Biocom
          California Academy of Family Physicians
          California Academy of Physician Assistants
          California Association of Nurse Practitioners
          California Association of Physician Groups
          California Chapter of the American College of Emergency  
          Physicians
          California Children's Hospital Association
          California Coverage and Health Initiatives
          California Disability Rights, Inc.
          California HealthCare Institute
          California Hepatitis Alliance
          California Hospital Association
          California Immunization Coalition
          California Medical Association
          California Optometric Association
          California Pharmacists Association
          California Primary Care Association
          California Public Health Association-North 
          California School Boards Association
          California School Employees Association
          California School Nurses Organization
          California State Association of Counties
          California State Parent-Teacher Association
          Carlsbad High School Parent-Teacher-Student Association
          Child Care Law Center
          Children Now 
          Children's Defense Fund California
          Children's Healthcare Is a Legal Duty, Inc.
          Children's Hospital Oakland
          Children's Specialty Care Coalition
          City of Berkeley
          City of Beverly Hills
          City of Pasadena
          County Health Executives Association of California
          County of Alameda
          County of Los Angeles
          County of Marin
          County of Santa Clara
          County of Santa Cruz
          County of Santa Cruz Democratic Party
          County of Yolo








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          Democratic Women's Club of Santa Cruz County
          First 5 California
          Foundation for Pediatric Health
          Health Officers Association of California
          Junior Leagues of California
          Kaiser Permanente
          Los Angeles Community College District
          Los Angeles County Supervisor Sheila Kuehl
          Los Angeles Unified School District
          March of Dimes California Chapter
          MemorialCare Health System Physician Society
          National Coalition of 100 Black Women Sacramento Chapter
          Osteopathic Physicians and Surgeons of California
                                                    Project Inform
          Providence Health and Services Southern California
          San Dieguito Union High School District
          San Francisco Unified School District
          Santa Monica Malibu Union Unified School District
          Secular Coalition for California
          Silicon Valley Leadership Group
          Solano Beach School District
          The Children's Partnership
          UAW Local 5810, Postdoctoral Researchers at the University of  
          California
          Hundreds of individuals


          OPPOSITION:   (Verified6/23/15)


          AWAKE California
          Association of American Physicians and Surgeons
          California Chiropractic Association
          California Naturopathic Doctors Association 
          California Nurses for Ethical Standards
          California ProLife Council
          California Right to Life Committee, Inc.
          Canary Party
          Capitol Resource Institute
          Educate. Advocate.
          Families for Early Autism Treatment
          Homeschool Association of California








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          National Vaccine Information Center
          Pacific Justice Institute Center for Public Policy
          ParentalRights.org
          SafeMinds
          Hundreds of individuals

           ASSEMBLY FLOOR:  46-31, 6/25/15
           AYES:  Alejo, Baker, Bloom, Bonilla, Bonta, Calderon, Campos,  
            Chau, Chiu, Cooper, Dababneh, Daly, Dodd, Eggman, Frazier,  
            Cristina Garcia, Eduardo Garcia, Gipson, Gomez, Gonzalez,  
            Gordon, Gray, Roger Hernández, Holden, Irwin, Jones-Sawyer,  
            Kim, Levine, Low, McCarty, Medina, Mullin, Nazarian,  
            O'Donnell, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas,  
            Santiago, Mark Stone, Thurmond, Ting, Weber, Wood, Atkins
           NOES:  Achadjian, Travis Allen, Bigelow, Brough, Brown, Burke,  
            Chang, Chávez, Cooley, Dahle, Beth Gaines, Gallagher, Gatto,  
            Grove, Hadley, Harper, Jones, Lackey, Linder, Lopez,  
            Maienschein, Mathis, Mayes, Melendez, Obernolte, Olsen,  
            Patterson, Steinorth, Wagner, Waldron, Wilk
           NO VOTE RECORDED:  Chu, Perea, Williams




          Prepared by:Melanie Moreno / HEALTH / 
          6/26/15 13:32:42


                                   ****  END  ****