BILL ANALYSIS Ó
SENATE COMMITTEE ON HUMAN SERVICES
Senator McGuire, Chair
2015 - 2016 Regular
Bill No: SB 792
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|Author: |Mendoza |
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|Version: |April 7, 2015 |Hearing | April 28, 2015 |
| | |Date: | |
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|Urgency: |No |Fiscal: |Yes |
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|Consultant|Mareva Brown |
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Subject: Day care facilities: immunizations: exemptions
SUMMARY
This bill prohibits a day care center or a family day care home
from employing any person after September 1, 2016, who has not
been immunized according to the Center for Disease Control and
Prevention's schedule for routine adult immunizations. It
specifies circumstances under which a person would be exempt
from the immunization requirement, based on medical safety and
current immunity. The bill also makes conforming changes to
statute defining the qualifications for day care center teachers
and for licensure as a family day care center.
ABSTRACT
Existing law:
1)Establishes the Child Day Care Facilities Act with the
California Department of Social Services (CDSS) as the
licensing entity for child care centers and family child care
homes, states Legislative intent to provide a comprehensive,
quality system for licensing child day care facilities to
ensure a quality day care environment and that good quality
child day care services are an essential service for working
parents. (HSC 1596.70, et seq.)
2)Defines a "Child day care facility" as a facility that
provides nonmedical care to children under 18 years of age in
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need of personal services, supervision, or assistance on less
than a 24-hour basis, as specified, and includes in that
definition day care centers, employer-sponsored child care
centers, and family day care homes. (HSC 1596.750)
3)Defines a "day care center" to mean any child day care
facility other than a family day care home, including infant
centers, preschools, extended day care facilities, and school
age child care centers (HSC 1596.76), and defines a "family
day care home" as a home that regularly provides care,
protection, and supervision for 14 or fewer children, in the
provider's own home, as defined. (HSC 1596.78.(a))
4)Establishes within the state Communicable Disease Prevention
and Control Act specific immunization requirements for
educational and child care facilities and prohibits each
governing entity of a facility 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. (HSC 120325)
5)Defines the required immunizations as a means for the eventual
achievement of total immunization of appropriate age groups
against the following childhood diseases:
a. Diphtheria.
b. Hepatitis B.
c. Haemophilus influenzea type b.
d. Measles.
e. Mumps.
f. Pertussis (whooping cough).
g. Poliomyelitis.
h. Rubella.
i. Tetanus.
j. Varicella (chickenpox), and
aa. Any other disease deemed appropriate by the
department, taking into consideration the recommendations
of the Advisory Committee on Immunization Practices of
the United States Department of Health and Human
Services, the American Academy of Pediatrics, and the
American Academy of Family Physicians. (HSC 120325)
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6)Waives the immunization requirement if the child's parent or
guardian files a written statement by a licensed physician to
the effect that the physical condition of the child or medical
circumstances relating to the child are such that immunization
is not considered safe. Requires the statement to indicate
the specific nature and probable duration of the medical
condition or circumstances that contraindicate immunization.
(HSC 120370)
7)Waives the immunization requirement if the child's parent,
guardian or the adult who has assumed responsibility for the
child's care and custody files a letter with the governing
authority stating that the immunization is contrary to his or
her beliefs (commonly referred to as a "personal belief
exemption.") (HSC 120365)
8)Permits a person to be hired as a teacher in a day care center
if he or she is at least 18 years of age, possesses a regional
occupation program certificate of training in child care
occupations, as defined, and has completed at least 95 hours
of classroom instruction in child care and development and
child care occupations and at least 150 hours in supervised
field experience in a licensed day care center or comparable
group child care program. (HSC 1597.055. (a) )
9)Requires family day care home to apply to CDSS for licensure
and to submit documentation related to financial security,
disaster planning, fire safety, and both fingerprint and
tuberculosis clearances for any adult in the home when
children are present. (HSC 1597.54)
10)Requires as of July 1, 2007, that the state enforce a
requirement for each general acute care hospital, in
accordance with the Centers for Disease Control guidelines, to
take all of the following actions:
a. Annually offer onsite influenza vaccinations, if
available, to all hospital employees at no cost to the
employee. Each general acute care hospital shall require
its employees to be vaccinated, or if the employee elects
not to be vaccinated, to declare in writing that he or
she has declined the vaccination.
b. Institute respiratory hygiene and cough etiquette
protocols, develop and implement procedures for the
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isolation of patients with influenza, and adopt a
seasonal influenza plan.
c. Revise an existing or develop a new disaster plan
that includes a pandemic influenza component. The plan
shall also document any actual or recommended
collaboration with local, regional, and state public
health agencies or officials in the event of an influenza
pandemic. (HSC 1288.7)
11)California Code of Regulations requires employers to make
available to all susceptible healthcare workers, as defined;
with occupational exposure all vaccine doses listed in
Appendix E. Doses listed in Appendix E include seasonal
influenza vaccine, measles, mumps, and rubella vaccine,
varicella vaccine, and tetanus-diphtheria-acellular pertussis
(Tdap) vaccine. Employers are required to ensure that
employees who decline to accept a recommended and offered
vaccination sign the declination statement. The requirement
applies to hospitals, skilled nursing facilities, clinics,
medical offices and other outpatient medical facilities, among
others. Outpatient medical facilities whose policy is not to
diagnose or treat aerosol transmissible diseases are not
required to comply with this standard if they meet certain
other conditions. (CCR Title 8. § 5199(h)(5))
12)California Code of Regulations requires health employers to
make seasonal influenza vaccine available to all employees at
hospitals, skilled nursing facilities, clinics, medical
offices and specified outpatient medical facilities who have
occupational exposure to the flu, and to ensure that each
employee who declines to accept the seasonal flu vaccine signs
a statement of declination. (CCR Title 8 § 5199(h)(10))
This bill:
1)Prohibits a person from being employed at a day care center or
a family day care home if he or she has not been immunized
according to the schedule for routine adult immunizations, as
recommended by the federal Advisory Committee on Immunization
Practices, with the exception of immunization against human
papillomavirus (HPV).
2)Exempts a person from this requirement only under either of
the following circumstances:
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a. The person submits a written statement from a
licensed physician declaring that because of the
person's physical condition or medical circumstances,
immunization is not safe. Requires the statement to
indicate the probable duration of the medical
condition or circumstances that contraindicate
immunization; or,
b. The person submits a written statement from a
licensed physician providing that the person has
evidence of current immunity to the diseases included
on the immunization schedule.
3)Makes provision of the evidence of current immunity, as
defined, a condition of hiring a teacher in a day care center.
4)Requires as a condition of licensure by CDSS that family day
care home applicants must provide evidence of current
immunity, as defined, for the applicant and any other person
who provides care and supervision to the children.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
Purpose of the bill:
The author states that communicable disease such as flu or the
measles may seem like a relative inconvenience to adults.
However, for very young children or others with underlying
health conditions, these conditions can be fatal. The author
writes that until children are fully vaccinated, they rely on
those around them to maintain community immunity to stop the
spread of disease. Day care settings, where children have close
contact with other children and with staff, can be host to
outbreaks, according to the author.
The author writes that by requiring employees of family day care
homes and day care centers to submit evidence of current
immunity, this will protect these vulnerable children by
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surrounding them with immunity even if they cannot be immunized
themselves. The bill would require providers to comply with the
recommendations for adult immunizations by the Advisory
Committee on Immunization Practices at the US Centers for
Disease Control (CDC), except for the recommended vaccine for
human papillomavirus (HPV).
Child Care
The availability of child care, both for families with
state-subsidized care and those who pay privately, has been a
source of concern in recent years. While the availability of
care grew steadily in the decade preceding the Recession, the
number of subsidized slots and of overall slots fell during and
after the Recession, as is shown in the chart below.<1>
Family child care home capacity, for example, fell by 20 percent
between 2008 and 2014. Families have testified that finding
quality, affordable child care is difficult. CDSS reports they
have licensed a total of 14,705 facilities with a total capacity
of 1,082,201, combining the capacity of Infant Centers,
School-Age Day Care Centers, DC Centers-Ill, and Day Care
Centers.
Child Immunizations
Vaccination coverage in California is at or near all-time high
levels. According to an August 2014 fact sheet by the California
Department of Public Health (DPH), 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. DPH would
like immunization rates to be as close to 100 percent as
possible, and is using national Healthy People 2020 objectives
as a benchmark to monitor progress.
Adult immunizations
The CDC's Advisory Committee on Immunization Practices (ACIP)
issues a recommended adult schedule, which was first published
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<1> Joint Senate and Assembly hearing on Child Care, April 14,
2015
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in 2002, and most recently updated in 2015. The recommendations
were approved the American Academy of Family Physicians, the
American College of Physicians, American College of
Obstetricians and Gynecologists and American College of
Nurse-Midwives, and are reflected in the chart below. Some
dosages are not recommended for adults with medical conditions
such as pregnancy and immune disorders. <2>
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|Vaccine |Age Group |19-21 years |22-26 years |27-49 years |50-59 years |60-64 years |e 65 years |
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|-------------------+-------------------------------------------|
|Influenza *,2 |?1 dose annually' |
|-------------------+-------------------------------------------|
|Tetanus, |Substitute 1-time dose of Tdap for Td |
|diphtheria, |booster; then boost with Td every 10 yrs |
|pertussis | |
|(Td/Tdap) *,3 | |
|-------------------+-------------------------------------------|
|Varicella *,4 |?2 doses' |
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|Human |?3 doses' | | | | |
|papillomavirus | | | | | |
|(HPV) Female *,5 | | | | | |
---------------------------------------------------------------
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|Human |?3 |doses'| | | | |
|papillomavirus | | | | | | |
|(HPV) Male *,5 | | | | | | |
---------------------------------------------------------------
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|Zoster 6 | | | | |?1 dose' |
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|Measles, mumps, |?1 or 2 doses' | | | |
|rubella (MMR) *,7 | | | | |
---------------------------------------------------------------
---------------------------------------------------------------
|Pneumococcal |?1-time |dose' |
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<2>
http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-sched
ule-bw.pdf
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|13-valent | | |
|conjugate (PCV13) | | |
|*,8 | | |
|-------------------+------------------------------------+------|
|Pneumococcal |?1 or 2 doses' |?1 |
|polysaccharide | |dose' |
|(PPSV23)8 | | |
---------------------------------------------------------------
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|Meningococcal *,9 |?1 or more doses' |
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|Hepatitis A *,10 |?2 doses' |
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|Hepatitis B *,11 |?3 doses' |
|-------------------+-------------------------------------------|
|Haemophilus |?1 or 3 doses' |
|influenzae type b | |
|(Hib) *,12 | |
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National Adult Immunization Plan
In February 2015, the U.S. Health and Human Services department
released a National Adult Immunization Plan, detailing efforts
to increase the compliance of adults with federally recommended
immunization schedules. The report noted that adult vaccination
rates remained low and variable across different demographic
groups.
According to the report, the health and productivity costs of
influenza are estimated to be as high as $87 billion per year.
Additionally, the CDC estimates that 4,000 adults die from
invasive pneumococcal disease, and somewhere between 3,000 and
50,000 deaths are due to seasonal influenza. The report cites
outbreaks of vaccine-preventable diseases, such as measles, and
suggests that the public health impact of these diseases will
grow with the aging of the nation's population. "The diminishing
function of the aging immune system reduces the immune response
to vaccination and underscores the need to develop more
effective products for older adults," according to the
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report.<3>
California requirements for adult vaccinations
State law mandates that each general acute care hospital require
its employees to be vaccinated against influenza annually, or if
the employee elects not to be vaccinated, to declare in writing
that he or she has declined the vaccination. (HSC 1288.7) State
law additionally mandates that all employees in general acute
care hospitals be offered a free influenza vaccine annually by
their employer, if the vaccine is available.
The California Code of Regulations additionally requires
employers at hospitals, skilled nursing facilities, clinics,
medical offices and specified outpatient medical facilities to
make available an annual influenza vaccine for employees who
have occupational exposure to the flu, and to ensure that each
employee who declines to accept the seasonal flu vaccine sign a
statement of declination.
The Code of Regulations requires those same employers to make
available to all susceptible healthcare workers who have
occupational exposure to specific airborne illnesses, all
vaccine doses listed in Appendix E, which include seasonal
influenza, measles, mumps, and rubella, varicella, and the
tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Employers
are required to ensure that employees who decline to accept a
vaccination that is recommended and offered sign a declination
statement.
Influenza vaccine
The influenza vaccine has been the focus of controversy, with
scientists debating its efficacy. According to the CDC's
question and answer page about the flu vaccine,
"Vaccine effectiveness will always vary from season to
season, based upon the degree of similarity between
the viruses in the vaccine and those in circulation,
as well as other factors. In years when the vaccine
strains are not well-matched to circulating strains,
----------------------
<3> National Adult Immunization Plan, National Adult Vaccine
Office, US Department of Health and Human Services, February
2015, pg 6.
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vaccine effectiveness is generally lower. In addition,
host factors also affect vaccine effectiveness. In
general, influenza vaccines are less effective among
people with chronic medical conditions and among
people age 65 and older, as compared to healthy young
adults and older children.
Studies indicated that in seasons when the influenza vaccine was
not especially well matched to the circulating virus strain, the
benefits of vaccination may be reduced. In one study, the CDC<4>
noted the vaccine was 60% effective among healthy persons and
48% among those with high-risk medical conditions during the
2003-2004 influenza season, when the vaccine strains were not
optimally matched to viruses in circulation (Herrera et al.,
2007).
It is not possible to predict how well the vaccine and
circulating strains will be matched in advance of the influenza
season, and how this match may affect vaccine effectiveness,
researchers concluded.
Other states
The CDC catalogs state laws for the vaccination of health care
workers. Just 12 states have requirements for any kind of
vaccination, although some states, including California, require
employers to offer vaccines to their health care staff under
certain exposure conditions. Most states with required
vaccinations for health care workers include exemptions for
personal beliefs; Alabama, New Mexico and several others do not.
Many states only mandate certain vaccines - the most prominent
being the Measles, Mumps and Rubella vaccine.
Vaccine mandates for other types of care providers, such as day
care providers, are not tracked nationally.
Related legislation:
SB 277 (Pan and Allen, 2015) eliminates the personal belief
exemption from the requirement that children receive specified
vaccines for certain infectious diseases prior to being admitted
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<4>
http://www.cdc.gov/flu/professionals/vaccination/effectivenessqa.
htm
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to any public or private elementary or secondary school or to
day care center.
SB 2109 (Pan, Chapter 821, Statutes of 2012) requires that if a
child requests an exemption from the school vaccination
requirement due to a personal belief, that an additional form
issued by the Department of Public Health (DPH) must accompany a
letter or affidavit for a personal belief exemption. The form
must include a signed attestation from a health care
practitioner that he or she provided information regarding the
benefits and risks of the immunization and the health risks of
the communicable diseases. The Governor included a message with
his signature on this bill, which stated, in part: "I will
direct (DPH) to allow for a separate religious exemption on the
form. In this way, people whose religious beliefs preclude
vaccinations will not be required to seek a health care
practitioner's signature."
AB 2386 (Leach, 2000) would have required adults working at an
adult residential care facility to be vaccinated against the flu
and pneumococcal viruses, and provided a personal belief
exemption to the mandate. Died in the Assembly Health Committee.
AB 2580 (Arambula, 2008) would have required pupils entering the
seventh grade to be fully immunized against pertussis by
receiving any necessary adolescent booster immunization. Held in
the Senate Appropriations Committee.
SB 676 (Ridley-Thomas, 2007) would have required pupils entering
the seventh grade to be fully immunized against pertussis. Held
in the Assembly Appropriations Committee.
SB 533 (Yee, 2007) would have added pneumococcus to the list of
diseases that pupils are required to be immunized against before
entry into any private or public elementary or secondary school,
child care center, day nursery, nursery school, family day care
home, or development center, except for children who are 24
months of age or older. Vetoed by the Governor, who stated that
a mandate for this vaccination was not necessary.
COMMENTS
Passage of this bill would mark both the first requirement for a
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non health-care provider in California to complete mandated
vaccines in order to maintain employment, and the first mandated
flu shot in the state, without an option to decline for personal
reasons. While SB 277 (Pan and Allen) seeks to eliminate the
personal belief exemption from the requirement for children to
receive vaccines prior to being admitted to day care or school,
it does not include a mandate for a flu vaccine.
State statute requires that hospitals offer onsite influenza
vaccines, if available, to hospital employees at no cost to the
employee. It additionally requires that each general acute care
hospital mandate its employees to be vaccinated, or if the
employee elects not to be vaccinated, to declare in writing that
he or she has declined the vaccine. Local jurisdictions in the
state have variously encouraged or required health care
providers to receive an annual flu shot, provided by their
employer, or to wear a mask while in contact with patients.
This bill permits day care providers to decline immunizations
for health reasons alone and requires employees to obtain their
flu shots on their own time and to pay any incurred costs. Staff
recommends the author align this bill more closely with the
existing statute for hospital workers, as follows:
1597.622. (a) Commencing September 1, 2016, a person shall not
be employed at a family day care home if he or she has not been
immunized according to the schedule for routine adult
immunizations, as recommended by the federal Centers for Disease
Control and Prevention's Advisory Committee on Immunization
Practices, with the exception of vaccination for human
papillomavirus (HPV).
(b) A person is exempt from the requirements of this section
only under either of the following circumstances:
(1) The person submits a written statement from a licensed
physician declaring that because of the person's physical
condition or medical circumstances, immunization is not safe.
The statement shall indicate the probable duration of the
medical condition or circumstances that contraindicate
immunization.
(2) If the The person submits a written statement by a licensed
physician providing that the person has evidence of current
immunity to one or more of the diseases included on the
immunization schedule described in subdivision (a).
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(3) The person submits a written declaration that he or she has
declined the influenza vaccination. This exemption applies only
to the influenza vaccine.
POSITIONS
Support:
Health Officers Association of California (Sponsor)
California Academy of Family Physicians
California Hospital Associaton
California Primary Care Association
County Health Executives Association of California
Children Now
Knowledge Universe
March of Dimes California Chapter
Oppose:
California Chiropractic Association
Educate Operate
45 Individuals
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