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 inparagraph (1) (2) of subdivision (b) ofSection 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