BILL ANALYSIS Ó
SB 792
Page A
Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Kansen Chu, Chair
SB
792 (Mendoza) - As Amended July 2, 2015
SENATE VOTE: 34-3
SUBJECT: Day care facilities: immunizations: exemptions.
SUMMARY: Requires day care center and family day care home
employees to be immunized against influenza, pertussis and
measles.
Specifically, this bill:
1)Prohibits the employment of a person at a day care center or a
family day care home, commencing September 1, 2016, if he or
she has not been immunized against influenza, pertussis and
measles.
2)Requires each employee to receive an influenza vaccination
between August 1 and December 1 of each year, except when an
exemption applies.
3)Exempts a day care center or family day care home employee
SB 792
Page B
from the immunization requirements provided for in this bill
if any of the following apply:
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;
b) The person submits a written statement from a licensed
physician providing that the person has evidence of current
immunity to influenza, pertussis, and measles;
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 was hired after December 1 of the previous
year and before August 1 of the current year. This
exemption applies only to the influenza vaccine.
4)Adds providing evidence of current immunity to influenza,
pertussis, and measles, as specified, to the current list of
requirements employees of day care centers and family day care
homes must meet as conditions of new or continued employment,
beginning September 1, 2016.
EXISTING LAW:
1)Establishes the Child Day Care Facilities Act with the
Department of Social Services (DSS) as the licensing entity
for child care centers and family child care homes, to ensure
that working families have access to healthy and safe child
care providers and that child care programs contribute
positively to a child's emotional, cognitive, and educational
SB 792
Page C
development, and are able to respond to, and provide for, the
unique characteristics and needs of children. (HSC 1596.70 et
seq.)
2)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, as defined. (HSC 1596.76)
3)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, for periods of less than
24 hours per day, while the parents or guardians are away, and
is either a large family day care home or a small family day
care home, as specified. (HSC 1596.78)
4)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. (HSC 1597.05)
5)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)
SB 792
Page D
6)Requires 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. (HSC 1597.54)
7)Requires DSS to perform random inspections each year in no
fewer than 20% of licensed facilities not subject to annual
inspections, including day care centers and family day care
homes. Provides that this percentage shall increase by 10% if
the total citations issued by the department exceeds the
previous year by 10%. Requires DSS to visit every facility no
less than every 5 years. (HSC 1597.09 and 1597.55a)
8)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). (HSC 120325)
9)Permits the Department of Public Health (DPH) to add to the
aforementioned list any other disease deemed appropriate,
SB 792
Page E
taking into consideration the recommendations of the Advisory
Committee on Immunization Practices of the United States
Department of Health and Human Services (ACIP), the American
Academy of Pediatrics, and the American Academy of Family
Physicians. (HSC 120325)
10)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, as specified. (HSC 120365)
11)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)
12)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
SB 792
Page F
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. 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)
13)Requires, within the California Code of Regulations, that
employers make specified vaccine doses, including seasonal
influenza vaccine, measles, mumps, and rubella vaccine,
varicella vaccine, and tetanus-diphtheria-acellular pertussis
(Tdap) vaccine available to all susceptible healthcare
workers, as defined, with occupational exposure. 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 complying with this standard if
they meet certain other conditions. (CCR Title 8 §5199(h)(5))
14)Requires, within the California Code of Regulations, that
health employers make the 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
SB 792
Page G
flu vaccine signs a statement of declination. (CCR Title 8
§5199(h)(10))
FISCAL EFFECT: According to the Senate Appropriations
Committee, pursuant to Senate Rule 28.8, negligible state costs.
COMMENTS:
Child care: Among other supports, the state's system of child
care and development programs accommodates parents by ensuring
their children are served in a healthy and safe environment
while they are at work, in training or seeking employment, and
it grants families access to programs that will help children
with their social, emotional, educational and physical
development. General child care and development programs are
funded with federal and state dollars, and serve children from
birth through 12 years of age.
The California Child Day Care Facilities Act governs the
licensure and operation of child day care centers and family day
care homes. This law and the associated regulations found in
Title 22 of the California Code of Regulations establish general
health and safety requirements, staff-to-child ratios, and
provider training requirements. The Community Care Licensing
Division (CCLD) of DSS is responsible for licensing and
monitoring the state's 10,453 day care centers, which, as of
June 30, 2014, provided 588,058 child care slots. CCLD is
required to conduct unannounced site visits of all licensed
child day care facilities and homes. At the very least, these
facilities and homes must be visited no less frequently than
once every five years. CCLD also conducts annual visits of
SB 792
Page H
facilities with poor histories of compliance and those that are
required to have yearly visits by federal law. Additionally,
30% of those facilities not required to be inspected yearly are
randomly selected for annual inspection. The 2015-16 budget
adopted further supports and reforms, including enacting
upcoming changes to the frequency of inspections: starting in
January 2017, DSS will increase inspections to once every three
years for all facilities.
Child immunizations: SB 277 (Pan), Chapter 35, Statutes of
2015, was recently signed into law to, as of January 1, 2016,
eliminate 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. Even before the
introduction and passage of that bill, immunization coverage
among two- to four-year-olds in licensed child care settings was
greater than or equal to 94% percent for each vaccine according
to a 2014-15 child care immunization assessment conducted by the
California Department of Public Health (DPH). (This survey was
conducted in 88% of California's licensed child care
facilities.)
Adult immunizations: The Advisory Committee on Immunization
Practices (ACIP), within the Centers for Disease Control and
Prevention (CDC), develops recommendations for the use of
vaccines to control diseases in the U.S. One of the ACIP's many
charges is to annually review the recommended schedule of
vaccines for adults, which was recently completed for 2015 and
then approved by ACIP, the American Academy of Family
Physicians, the American College of Obstetricians and
Gynecologists, the American College of Physicians, and the
SB 792
Page I
American College of Nurse-Midwives.<1> According to the ACIP's
charter:
"The committee also provides recommendations on
contraindications and precautions for use of the vaccine and
related agents and provides information on recognized adverse
events. Committee deliberations on use of vaccines to control
disease in the U.S. shall include consideration of disease
epidemiology and burden of disease, vaccine efficacy and
effectiveness, vaccine safety, economic analyses and
implementation issues."
The U.S. Department of Health and Human Services released a
draft of its National Adult Immunization Plan in February of
this year, which describes the nation's low adult vaccination
rates and emphasizes the importance of vaccines in improving
overall quality of life and saving lives. The four key goals of
the five-year plan are to: strengthen the adult immunization
infrastructure; improve access to adult vaccines; increase
community demand for adult immunizations; and foster innovation
in adult vaccine development and vaccination-related
technologies. Within each of the four goals are objectives that
include: reducing financial barriers for individuals who
receive vaccines routinely recommended for adults, increasing
the use of Immunization Information Systems and Electronic
Health Records to collect and track adult immunization data, and
other objectives that promote positive societal impacts.
Employee vaccination requirements in other states: A CDC
database tracks state law requirements for the vaccination of
---------------------------
<1>
http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-sched
ule-bw.pdf
SB 792
Page J
health care workers. Twelve states have some sort of
vaccination requirement, and 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; some, such as New York and New Mexico do not.
Additionally, in many states where vaccinations are mandated,
only certain ones are required, the most predominant of which
are the Measles, Mumps and Rubella vaccines.
Current licensing requirements for employees: Licensing
standards and provider and employee requirements for all
licensed child care settings throughout the state are outlined
within Title 22 of the California Code of Regulations. Pursuant
to those regulations, all day care center and family day care
home providers and employees are already required to be clear of
tuberculosis based on a test performed not more than one year
before or seven days after employment in the child care setting.
As with the requirements currently set forth in statute and
regulations related to child care licensing, CCLD licensing
program analysts (LPAs) will need to verify compliance with the
immunization requirements included in this bill through a review
of records during licensing visits to a day care center or
family day care home.
Need for 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 (community immunity). This bill will
protect children in day care by requiring those who care for
them to maintain immunity. Some diseases, such as the flu,
cause only a relative inconvenience to healthy adults. However,
this same disease can require hospitalization and perhaps even
be fatal in an infant or an individual with a suppressed immune
SB 792
Page K
system. Last year in California, ten children died of
influenza. During the last major pertussis outbreak in 2010,
there were 9,000 cases of whooping cough and ten infant deaths.
We have also seen a resurgence of measles, which can cause
hospitalization and lifetime complications, including deafness.
Out of every 1,000 people that contract measles, one or two will
die, even with the best standard of care. By requiring
vaccination for pre-school workers, vulnerable children will be
"cocooned" from potentially serious illness, and day care
centers will be a safe and healthy place for our little ones to
learn and play."
Support: The Child Care Law Center explains the everyday impact
of the current lack of vaccination requirements for child care
providers, stating, "Child Care Law Center receives questions
from child care providers who ask about whether they can require
their employees to get vaccinated against diseases that are most
harmful to children. They have serious concerns about the
health of the babies and other children with medical conditions
in their care who cannot obtain vaccinations. Child care
providers are upset when they find out that they cannot help
protect unimmunized children from getting certain communicable
diseases from their staff."
Opposition: Your Family Your Choice writes, "Passing this bill
would mean endangering the field of child care by reducing an
already threatened commodity of otherwise qualified employees.
The only way these individuals could avoid the health risk of
vaccination is to leave this field of work altogether, further
draining the already small pool of qualified candidates for
employment."
Staff Comments: While access to vaccines, including cost
barriers, contraindications for pregnant women, and difficulties
proving immunization to certain diseases are natural concerns
for the child care workforce and have been enumerated by
SB 792
Page L
individuals concerned with the implications of this bill, a
number of factors help decrease the overall impact.
Proof of immunization: This bill is not prescriptive with
respect to how a person will work with his or her physician to
provide evidence of current immunity, which offers more
flexibility than having to locate old immunization records or
simply revaccinate. According to the author's office, disease
immunity information can be gathered through the results of an
antibody titers test, which tests the level of antibodies in a
person's blood. Instead of vaccination, a day care teacher can
submit to a simple blood test to verify immunity. (The test
could also reveal the need for a vaccine booster to continue
immunity). To the extent information has been entered, a
physician could also search the California Immunization
Registry, which is a secure, statewide immunization information
system.
Cost: According to the sponsor of this bill, the Health
Officers Association of California, out-of-pocket expenses for
individuals required to comply with this bill should be minimal.
Under the federal Patient Protection and Affordable Care Act,
and in the spirit of prevention, most insurance plans are
required to cover vaccinations for all ACIP-recommended vaccines
free of copayment or coinsurance. Additionally, local health
departments offer vaccines at no cost or at a discounted rate.
For a prospective day care teacher without health insurance and
without access to a local health department, measles vaccines
cost around $80, the pertussis vaccine costs around $50 and flu
shots can cost around $15. While the flu shot - if the employee
doesn't opt out of it - is required to be received annually, the
other two vaccines are recommended on a prolonged schedule,
therefore reducing the annual costs to comply with this bill.
Pregnancy: Of particular concern to opponents of this bill is
how it will affect women who are pregnant or could become
SB 792
Page M
pregnant. While the CDC does cite a contraindication for the
measles vaccine for pregnant women, it is important to remember
the manner in which vaccinations are provided. Prior to
vaccination, a conversation can and should be had with the
administering health care professional about a woman's potential
pregnancy. Additionally, the medical condition exemption
provided for in this bill should cover this contraindication and
waive the vaccination requirement.
Delayed implementation: Because the requirements of this bill
will not be implemented until September of 2016, day care
teachers have time to comply and licensees have time to work
with their local health departments and disseminate information
to their current and prospective employees.
Still, this bill will establish a first of its kind requirement
for a particular workforce to be immunized with very few
opportunities to decline. While this bill seeks to further
protect children by establishing immunization requirements for
workers in day care centers and family child care homes,
acknowledging the devastating impact certain preventable
diseases can have on young children, it is not based on
information showing high levels of unimmunized child care
teachers. The Committee may wish to have the author further
explain the rationale for applying this requirement to a
particular group of individuals and why the requirements are
more stringent than what exists for other professionals.
RECOMMENDED TECHNICAL AMENDMENT:
One of the conditions for exemption from the immunization
requirement established in this bill is submission of a written
statement from a licensed physician providing that the person
has evidence of current immunity to influenza, pertussis, and
measles. However, while this language is clear for day care
SB 792
Page N
centers, the corresponding provision that this bill adds to
Health & Safety Code Section 1597.622 specifies that an
exemption can be given for "a written statement by a licensed
physician providing that the person has evidence of current
immunity to one or more of the diseases described in subdivision
(a)." In order to provide consistency and greater clarity
around the requirements for the exemption, committee staff
recommends the following technical amendment to page 5 of the
bill:
21(2) The person submits a written statement by a licensed
22physician providing that the person has evidence of current
23immunity to one or more of the diseases described in
subdivision
24(a).
PRIOR LEGISLATION:
SB 277 (Pan and Allen), Chapter 35, Statutes of 2015, eliminates
the personal belief exemption 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 792
Page O
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 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 2580 (Arambula) 2008, would have required pupils entering the
seventh grade to be fully immunized against pertussis by
receiving any necessary adolescent booster immunization. Died
on the Senate Appropriations Committee suspense file.
SB 676 (Ridley-Thomas) 2007, would have required pupils entering
the seventh grade to be fully immunized against pertussis. Died
on the Assembly Appropriations Committee suspense file.
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.
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
SB 792
Page P
Committee.
SECOND COMMITTEE OF REFERENCE . This bill was previously heard
in the Assembly Health Committee on June 30, 2015 and was
approved on a 17-1 vote.
REGISTERED SUPPORT / OPPOSITION:
Support
Health Officers Association of California (HOAC), sponsor
Alameda County Board of Supervisors
American Academy of Pediatrics
American Nurses Association\California (ANA\C)
California Academy of Family Physicians
California Academy of Preventive Medicine (CAPM)
California Federation of Teachers (CFT)
California Hospital Association (CHA)
SB 792
Page Q
California Medical Association (CMA)
California Primary Care Association (CPCA)
California Public Health Association-North (CPHA-N)
Child Care Law Center
Children Now
County Health Executives Association of CA (CHEAC)
First 5 California
Knowledge Universe
Los Angeles County Board of Supervisors
March of Dimes California Chapter
National Association of Social Workers, CA (NASW-CA)
Santa Clara County Board of Supervisors
Opposition
SB 792
Page R
Educate. Advocate.
California Coalition for Health Choice
Your Family Your Choice
440 Individuals
Analysis Prepared by:Myesha Jackson / HUM. S. / (916)
319-2089