BILL ANALYSIS Ó
SB 792
Page 1
Date of Hearing: June 30, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
792 (Mendoza) - As Amended June 22, 2015
SENATE VOTE: 34-3
SUBJECT: Day care facilities: immunizations: exemptions.
SUMMARY: Prohibits, after September 1, 2016, a day care center
or a family day care home from employing any person who has not
been immunized against measles, pertussis, and influenza.
Specifies circumstances under which a person would be exempt
from the immunization requirement based on medical safety,
current immunity, or employee declination. Specifically, 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
against measles and pertussis, and has received an annual
seasonal influenza vaccine.
2)Exempts a person from this requirement only under the
following circumstances:
SB 792
Page 2
a) The person submits a written statement from a licensed
physician declaring that immunization is not safe because
of the person's physical condition or medical
circumstances. Requires the statement to indicate the
probable duration of the medical condition or circumstances
that contraindicate immunization;
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; or,
c) The person submits a written declaration that he or she
has declined the influenza vaccination. This exemption
applies only to the influenza vaccine; or,
d) The person is temporarily exempt from influenza
vaccination if hired after December 1, until August 1.
3)Makes conforming changes to statute defining the
qualifications for day care center teachers and for licensure
as a family day care center, including:
a) Makes provision of the evidence of current immunity, as
defined, a condition of hiring a teacher in a day care
center; and,
b) Requires as a condition of licensure by the California
Department of Social Services (DSS) that family day care
home applicants must provide evidence of current immunity,
SB 792
Page 3
as defined, for the applicant and any other person who
provides care and supervision to the children.
EXISTING LAW:
1)Establishes the Child Day Care Facilities Act with DSS 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.
2)Defines a "child day care facility" as a facility that
provides nonmedical care to children under 18 years of age in
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.
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, 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.
SB 792
Page 4
4)Establishes within the state Communicable Disease Prevention
and Control Act specific immunization requirements for
educational and child care facilities and prohibits the
governing authority of a school or other institution from
unconditionally admitting any person as a pupil of private or
public elementary or secondary schools, child care centers,
day nurseries, nursery schools, family day care homes, or
development centers, unless, prior to first admission to that
institution, he or she has been fully immunized against
diphtheria, Haemophilus influenzae type b (Hib), measles,
mumps, pertussis (whooping cough), poliomyelitis, rubella,
tetanus, hepatitis b (except after 7th grade), and varicella
(chickenpox).
5)Permits the Department of Public Health (DPH) to add to the
list in 4) above 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.
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.
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
SB 792
Page 5
her beliefs (commonly referred to as a "personal belief
exemption" or PBE).
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.
9)Requires a family day care home to apply to DSS 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.
10)Allows a day care center licensee 30 days after the
employment of a staff person or enrollment of a child to
secure records requiring information from sources not in the
control of the licensee or employee, such as physician
examinations, immunization confirmations, or proof of
educational qualifications. An extension can be granted where
the licensee can demonstrate that further delays are beyond
the control of the licensee.
11)Requires as of July 1, 2007, that the state enforce a
requirement for each general acute care hospital, in
accordance with the CDC guidelines, to take all of the
following actions:
SB 792
Page 6
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
isolation of patients with influenza, and adopt a seasonal
influenza plan; and
c) Revise an existing or develop a new disaster plan that
includes a pandemic influenza component. Requires the plan
to also document any actual or recommended collaboration
with local, regional, and state public health agencies or
officials in the event of an influenza pandemic.
12)Requires, under the current regulation, employers to make
available to all susceptible healthcare workers with
occupational exposure specified vaccine doses, including
seasonal influenza vaccine, measles, mumps, and rubella
vaccine, varicella vaccine, and tetanus-diphtheria-acellular
pertussis (Tdap) vaccine. Requires employers to ensure that
employees who decline a recommended and offered vaccination
sign the declination statement. Applies this requirement to
hospitals, skilled nursing facilities, clinics, medical
offices and other outpatient medical facilities, among others.
Exempts outpatient medical facilities whose policy is not to
diagnose or treat aerosol transmissible diseases from
SB 792
Page 7
complying with this standard if they meet certain other
conditions.
13)Requires, under current regulation, health facility 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.
14)Under the federal Patient Protection and Affordable Care Act,
requires all Health Insurance Marketplace plans and most other
private insurance plans to cover, free of copayment or
coinsurance, vaccinations for all ACIP-recommended vaccines.
FISCAL EFFECT: According to the Senate Appropriations
Committee, pursuant to Senate Rule 28.8, negligible state costs.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, children in
day care settings have close, intimate contact with each other
and with the staff who work there. Many of these children are
too young to be fully immunized against potentially serious
communicable diseases. Children who are too young to be
vaccinated rely on those around them to be immunized to
prevent the spread of disease. The author states that this
bill will protect children in day care by requiring those who
care for them to maintain immunity.
SB 792
Page 8
2)BACKGROUND. The diseases that vaccines prevent can be
dangerous, or even deadly. According to the CDC, vaccines
reduce the risk of infection by working with the body's
natural defenses to help it safely develop immunity to
disease. When bacteria or viruses invade the body, they
attack and multiply, creating an infection. The immune system
then has to fight the illness. Once it fights off the
infection, the body is left with a supply of cells that help
recognize and fight that disease in the future. Vaccines
contain the same antigens or parts of antigens that cause
diseases, but the antigens in vaccines are either killed or
greatly weakened. This exposure to the antigens teaches the
immune system to develop the same response as it does to the
real infection so the body can recognize and fight the disease
in the future.
Public health experts agree that vaccines represent one of the
greatest achievements of science and medicine in the battle
against disease. Vaccines are responsible for the control of
many infectious diseases that were once common around the
world, including polio, measles, diphtheria, pertussis,
rubella, mumps, tetanus, and Hib meningitis. Vaccines 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.
3)YOUNG CHILDREN ARE PARTICULARLY AT RISK. Some diseases, such
as the flu, cause only a relative inconvenience to healthy
adults. However, this same disease can require
hospitalization and be potentially fatal for infants or
SB 792
Page 9
individuals with suppressed immune systems. Importantly, many
vaccines require multiple doses before a child is protected
against the disease, and children in day care settings are
often too young to complete the recommended series of
vaccinations.
a) Pertussis is a highly contagious bacterial disease that
can be spread by coughing. People with pertussis have
severe coughing attacks that can last for months. Infants
too young for vaccination are at greatest risk for
life-threatening cases of pertussis. Pertussis
vaccinations are given starting at two months of age, but
multiple doses are required before the child is considered
fully immunized. According to DPH, during a major
pertussis outbreak in 2010, there were 9,000 cases of
pertussis resulting in 10 infant deaths. In 2014, there
were 11,114 reported cases of whooping cough with three
infant deaths. As of June 1, 2015 there have been 2,552
new cases of pertussis in California this year. Sixty-two
infants younger than four months of age have been
hospitalized and one death was reported in an infant that
contracted pertussis at three weeks of age.
b) Measles is a highly contagious viral disease, and is
considered the most deadly of all childhood rash/fever
illnesses. It is recommended that children receive their
first measles vaccination at 12 to 15 months; to be most
effective, a second dose is recommended at four to six
years. Measles is particularly dangerous for babies and
young children. From 2001-13, 28% of children younger than
five years old who had measles had to be treated in the
hospital. For some children, measles can lead to
pneumonia, lifelong brain damage, deafness, or death.
According to the CDC, the United States declared that
measles was eliminated from this country in 2000; however,
measles is one of the first diseases to reappear when
vaccination coverage rates fall. In 2014, there were over
SB 792
Page 10
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 December 2014
outbreak in California, which is one of five outbreaks so
far this year reported by the CDC.
c) Influenza, or flu, is a contagious respiratory illness
caused by influenza viruses. The CDC recommends a yearly
flu vaccine for everyone six months of age and older as the
first and most important step in protecting against this
serious disease. Because there are many different flu
viruses, the flu vaccine is redesigned annually to protect
against the flu strains that research indicates will cause
the most illness during the flu season. Last year in
California, 10 children died of influenza. According to
the CDC's nationwide surveillance, 142 children passed away
during the 2014-15 flu season due to complications with the
flu, bringing the total of pediatric deaths since 2004 to
over 1,000.
4)COMMUNITY IS LOCAL. 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 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.
SB 792
Page 11
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 masks 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 of the community
that a child interacts with on a daily basis, such as family
members, teachers, and other students, is more relevant than a
statewide number.
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. In day care settings, small classroom
size and low teacher-to-student ratio has raised concerns that
teachers and workers should also be required to be immunized
in order to ensure the community interacting daily with very
young children maintains a vaccination level high enough to
protect community immunity.
SB 792
Page 12
5)ADULT VACCINE REQUIREMENTS IN THE HEALTHCARE WORKFORCE. State
law mandates that each general acute care hospital require its
employees to be vaccinated against influenza annually. 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. In each of these settings,
the employee may elect not to be vaccinated, and file a
declaration in writing that he or she has declined the
vaccination.
State regulations require the same employers above to make
available to all susceptible healthcare workers who have
occupational exposure to specific airborne illnesses, which
include seasonal influenza, measles, mumps, and rubella,
varicella, and the Tdap vaccine. Employers are required to
ensure that employees who decline to accept a vaccination that
is recommended and offered sign a declination statement.
6)ADULT WORKER VACCINATIONS IN OTHER STATES. According to the
CDC, 12 states have requirements for some vaccination of
healthcare workers. Some states, including California,
require employers to offer vaccines to their healthcare staff
under certain exposure conditions. Most states with required
vaccinations for healthcare 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. Some
states have various requirements for daycare workers. In
2014, Texas passed a law requiring child-care facilities to
develop and implement a policy concerning vaccination of
employees. Colorado requires staff at day care centers be
SB 792
Page 13
current for all immunizations routinely recommended for adults
by their health care provider.
7)SUPPORT. The Health Officers Association of California writes
that given that child care workers have close, intimate
contact with children who are unable to be fully immunized, it
is important to ensure that these dedicated professionals are
not inadvertently exposing children to potentially fatal, yet
vaccine-preventable, childhood diseases. The California
Primary Care Association states that vaccines are a modern
medical miracle, but they are only effective if people working
with our vulnerable children are required to be vaccinated.
Knowledge Universe states the U.S. is experiencing a
multi-state outbreak of measles, and at one child care center
alone this year, 12 infants became sick with the measles as
this highly contagious illness spread from one infant to all
other infants in the center. The Santa Clara County Board of
Supervisors and other supporters state that it is important to
ensure that child care professionals are not inadvertently
exposing children to potentially fatal, yet
vaccine-preventable, childhood diseases.
8)OPPOSITION. The California Right to Life Committee states
that this bill places an unwarranted burden on child care
employees, as well as an unnecessary mandate that day care
owners must enforce. California Coalition for Health Choice
states that "this bill capitalizes on fears of a nonexistent
public health crisis, discriminates against select groups, and
offers no sound incentives to expand public health education."
Your Family, Your Choice opposes the bill unless it is
amended to include a personal belief or religious exemption.
They also request amendments to exclude from the mandate
caregivers who do not care for infants.
9)RELATED LEGISLATION. SB 277 (Pan and Allen) eliminates the
SB 792
Page 14
non-medical exemptions from the requirement that children
receive specified vaccines for certain infectious diseases
prior to being admitted to any public or private elementary or
secondary school or day care center. SB 277 was approved by
the Assembly on June 25, 2015 by a vote of 46 - 30 and is
currently pending concurrence of Assembly amendments in the
Senate.
10)DOUBLE REFERRAL. This bill is double referred; upon passage
in this Committee, this bill will be referred to the Assembly
Human Services Committee.
11)POLICY COMMENT.
a) Current law requires employers to collect and keep
specific records for each new hire. This bill would
require an annual review of employee records for influenza
vaccination. The Committee may wish to consider whether
this bill would require additional burden on employers to
annually review employee files, remind employees about
requirements, and keep track of documentation.
b) The Department of Industrial Relations has, through
regulation, created a standardized form that health care
employees sign, and employers keep on file, when the
employee declines offered vaccination. The Committee may
wish to consider whether a standardized declination form
would be useful for the child care industry as well.
12)SUGGESTED AMENDMENTS.
a) The medical exemption in the bill, as drafted, may
require the physician to disclose confidential medical
SB 792
Page 15
information that could be protected by state and federal
law. To address this privacy concern, the bill should be
amended on page 2 as follows:
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.
b) Technical Amendment: An incorrect cross-reference should
be amended on page 3, line 22 of the bill as follows:
Commencing September 1, 2016, has provided evidence of
current immunity, as described in paragraph (1) (2) of
subdivision (b) of Section 1596.7995.
REGISTERED SUPPORT / OPPOSITION:
Support
Health Officers Association of California (sponsor)
Alameda County Board of Supervisors
American Academy of Pediatrics
SB 792
Page 16
American Nurses Association \ California
California Academy of Family Physicians
California Academy of Preventive Medicine
California Federation of Teachers
California Hospital Association
California Medical Association
California Public Health Association - North
California Primary Care Association
Child Care Law Center
Children Now
County Health Executives Association of California
First 5 California
Knowledge Universe
SB 792
Page 17
Los Angeles County Board of Supervisors
March of Dimes, California Chapter
National Association of Social Workers - California
Santa Clara County Board of Supervisors
Opposition
AWAKE California
California Right to Life Committee, Inc.
Canary Party - California
Educate. Advocate.
LifeWays North America (unless amended)
National Vaccine Information Center
Your Family, Your Choice (unless amended)
Hundreds of individuals
Analysis Prepared by:Dharia McGrew / HEALTH / (916)
319-2097