BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 354
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AUTHOR: Arambula
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AMENDED: April 28, 2009
HEARING DATE: June 17, 2009
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CONSULTANT:
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Orr/
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SUBJECT
Health: immunizations
SUMMARY
Deletes certain age limits for specified childhood
immunizations required for admission to specified schools
or child care centers, and requires the Department of
Public Health (DPH) to consider the immunization
recommendations of the American Academy of Family
Physicians.
CHANGES TO EXISTING LAW
Existing law:
States legislative intent to provide a means for specified
age groups to achieve total immunization against certain
childhood diseases, to the extent that funds are
appropriated for this purpose from the annual Budget Act.
Prohibits the governing authority of a school or other
institution from unconditionally admitting any person as a
pupil of any private or public elementary or secondary
school, child care center, day nursery, nursery school,
family day care home, or development center, unless prior
to his or her first admission to that institution he or she
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has been fully immunized against the following diseases:
Diphtheria, Haemophilus influenzae type b, Measles, Mumps,
Pertussis, Poliomyelitis, Rubella, Tetanus, Hepatitis B,
and Varicella.
Establishes several exceptions to these requirements, based
on the age of the child:
Haemophilus influenzae type b immunization only applies
to children who have not reached the age of four and a
half years old.
Mumps immunization only applies to children who have
not reached the age of seven years old.
Pertussis (whooping cough) immunization only applies to
children who have not reached the age of seven years
old.
Hepatitis B immunization is required of all children
entering kindergarten after August 1, 1997. Existing
law prohibits a governing authority to unconditionally
admit any pupil to the 7th grade unless the pupil has
been fully immunized, beginning July 1, 1999.
Varicella (chickenpox) immunization is required only if
a person has not already been admitted into a California
public or private school at the kindergarten level or
above. Existing law stipulates that Varicella
immunization requirements are operative to the extent
that funds are appropriated for this purpose from the
annual Budget Act and allows DPH to adopt emergency
regulations to implement this requirement, as deemed
necessary by the Office of Administrative Law for the
immediate preservation of the public health or general
welfare, to remain in effect for no longer than 180
days.
Allows DPH to add any other disease that is consistent with
the most current immunization recommendations of the
Centers for Disease Control and the American Academy of
Pediatrics to their list of required vaccinations.
This bill:
Requires DPH to additionally consider the recommendations
of the American Academy of Family Physicians when adding
any other disease to their list of required vaccinations.
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Deletes current exceptions to immunization requirements
based on age or grade, specifically for Haemophilus
influenzae type b, Mumps, Pertussis, and Varicella.
Deletes the requirement that Hepatitis B immunization can
only be required of children entering kindergarten after
August 1, 1997.
By deleting some of these exceptions, the DPH will have the
latitude to adopt other regulations regarding immunization
requirements for school-age children.
Deletes the stipulation that the immunization requirements
for Varicella are operative to the extent that funds are
appropriated for this purpose from the annual Budget Act.
Deletes the provision allowing DPH to adopt emergency
regulations to implement the Varicella immunization
requirement.
FISCAL IMPACT
The Assembly Appropriations Committee estimates net savings
to the extent this bill reduces future health costs, by
increasing immunization efficacy and rates.
BACKGROUND AND DISCUSSION
According to the author, AB 354 will reduce rates of
pertussis infections by allowing DPH to place a pertussis
booster vaccine among the necessary vaccinations for
students prior to the start of the 7th grade. Existing
childhood immunization against pertussis does not provide
the lasting immunity needed to control the disease and
protect public health. The author asserts that this bill
is necessary to DPH's efforts to adopt more updated
vaccination requirements that are needed to effectively
reduce incidences of this disease.
Background
Pertussis (whooping cough) is an acute, infectious cough
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illness that is highly communicable and can cause severe
disease, particularly among very young children. According
to the Centers for Disease Control and Prevention (CDC),
pertussis remains endemic in the United States despite
routine childhood pertussis vaccination for more than half
a century. The CDC asserts that the main reason for the
continued circulation of pertussis is that the immunity
created by the vaccine can wane approximately 5-10 years
after completion of the childhood pertussis vaccination,
leaving adolescents and adults susceptible to the disease.
The disease is most detrimental in infants less than one
year of age, and can be fatal. Older preschool children and
school-age siblings who are not fully vaccinated and who
develop pertussis can easily become sources of infection
for infants. Adults can also transmit pertussis to
unvaccinated or incompletely vaccinated infants and young
children.
In 2005, the first pertussis booster vaccines (referred to
as Tdap, a combination of vaccines for tetanus, diphtheria,
and pertussis) were licensed in the United States for use
in adolescents and adults. Since 2005, Tdap vaccine has
been included in DPH's Vaccines for Children (VFC) Program,
a federal program that provides recommended immunizations
to eligible clients through the age of 18 years.
Vaccine recommendations
According to the CDC's Advisory Committee on Immunization
Practices (ACIP), optimal response to a vaccine depends on
multiple factors, including the nature of the vaccine and
the age and immune status of the recipient. Recommendations
for the age at which vaccines are administered are
influenced by age-specific risks for disease, age-specific
risks for complications, ability of persons of a certain
age to respond to the vaccine, and potential interference
with the immune response by passively transferred maternal
antibody. Vaccines are recommended for members of the
youngest age group at risk for experiencing the disease for
whom efficacy and safety have been demonstrated.
ACIP consists of 15 experts selected by the Secretary of
the United States Department of Health and Human Services
to provide advice and guidance to the Secretary, the
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Assistant Secretary for Health, and the CDC on the most
effective means to prevent vaccine-preventable diseases.
ACIP includes representation by a variety of national
organizations, including the American Academy of Pediatrics
(AAP) and the American Academy of Family Physicians (AAFP)
as well as other federal departments, such as the Centers
for Medicare and Medicaid Services, Food and Drug
Administration, and the National Vaccine Program Office.
The overall goals of the ACIP are to provide advice which
will assist in reducing the incidence of vaccine
preventable diseases, and to increase the safe usage of
vaccines and related biological products. ACIP, in
conjunction with AAP and AAFP, publishes a schedule of
recommended childhood and adolescent immunizations and
revises it annually. ACIP is the only entity in the federal
government which makes such recommendations.
American Academy of Family Physicians
The American Academy of Family Physicians is one of the
largest national medical organizations, representing more
than 94,000 family physicians, family medicine residents,
and medical students nationwide. Founded in 1947, its
mission has been to preserve and promote the science and
art of family medicine and to ensure high-quality,
cost-effective health care for patients of all ages.
Related legislation
SB 158 (Wiggins) 2009 requires health care service plan
contracts and health insurance policies that provide
coverage for cervical cancer treatment or surgery to also
provide coverage for a human papillomavirus (HPV) vaccine.
Pending in the Assembly Appropriations Committee.
SB 249 (Cox) 2009 requires DPH to include children who are
at least 11 years of age in any meningococcal disease
public awareness campaign it implements. Pending in the
Assembly Health Committee.
AB 977 (Skinner) 2009 requests the California Pharmacists
Association to provide information to specified legislative
committees on the status of immunization protocols between
independent pharmacists and physicians. Pending in the
Assembly Health Committee.
AB 1021 (Emmerson) 2009 was originally nearly identical to
this bill, and was sponsored by DPH. This bill was
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substantively amended to deal with an unrelated topic.
AB 1201 (V. Manuel Perez) 2009 requires a health care
service plan or health insurer that provides coverage for
childhood and adolescent immunizations to reimburse a
physician or physician group the entire cost of acquiring
and administering the vaccine, and prohibits a health plan
or insurer from requiring cost-sharing for immunizations.
Held on suspense in the Assembly Appropriations committee.
AB 1251 (Saldana) 2009 required the Immunization Branch of
DPH, after consulting with the Office of Multicultural
Health, to create a public outreach campaign, including the
creation of an informational internet website, to educate
citizens of the state with Asian, Southeast Asian, or
Pacific Islander backgrounds on the importance of
immunization against hepatitis B. Gutted and amended into
an unrelated bill.
Prior legislation
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 claimed that a mandate
for this vaccination was not necessary.
SB 676 (Ridley-Thomas) 2007 would have required pupils
entering the 7th grade to be fully immunized against
pertussis. Required the DPH to maintain a list of diseases
and conditions for which immunization is required prior to
entry into any private or public elementary or secondary
school, child care center, day nursery, nursery school,
family day care home, or development center. Permited the
DPH to modify the list at any time and requires the DPH to
annually review and modify immunization requirements for
pupils. Exempted modification of the list established by
the DPH from administrative regulation and rulemaking
requirements under existing law. Held on suspense in
Assembly Appropriations Committee.
SB 1179 (Aanestad) 2008 would have deleted DPH's authority
to add diseases to the list of those requiring
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immunizations prior to entry to any private or public
elementary or secondary school, child care center, day
nursery, nursery school, family day care home, or
development center. Set for hearing in the Senate Health
Committee, but was pulled at the author's request.
AB 16 (Evans) 2008 as introduced by Assemblymember
Hernandez in 2007, would have required all female students
to be vaccinated for HPV prior to school admission. The
bill was amended before it passed the Assembly to instead
establish a process for California to adopt ACIP vaccine
recommendations as a requirement for admission to schools
and day care centers. In the Senate, the bill changed
authorship to Assemblymember Evans and the bill was amended
to require health plans and health insurers to provide
coverage for HPV vaccine. Vetoed by the governor, citing
concerns over the cost of a new mandate.
AB 2580 (2008) was nearly identical to this bill, but added
a mandate requiring pupils entering the 7th grade to be
fully immunized against pertussis. Held on suspense in the
Senate Appropriations Committee.
AB 106 (Berg) Chapter 378, Statutes of 2007, requires a
general acute care hospital to offer immunizations for
influenza and pneumococcal disease to its inpatients aged
65 years or older, each year commencing October 1 to the
following April 1, inclusive, if it has the vaccine in its
possession, prior to the patients' discharge.
AB 1429 (Evans) 2007 preceded and was substantially similar
to the final version of AB 16 (Evans, 2008). Vetoed by the
governor, with a similar veto message.
AB 576 (Wolk) Chapter 329, Statutes of 2006 requires, among
other things, DPH to submit by January 31, 2008, a
sustainability plan for full funding of a statewide
immunization information system, as specified.
Arguments in support
Supporters such as the California Medical Association claim
this bill will make statutory vaccination requirements more
consistent with current federal recommendations for
childhood immunizations. The California Academy of Family
Physicians argues that pediatric vaccinations are some of
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the safest and most cost-effective public health inventions
of this century. The California Immunization Coalition
claims this bill could lead to Medi-Cal savings of over $16
million, not including savings in the private sector.
AFSCME believes this bill will help to ensure that schools
are healthy and disease free.
Arguments in opposition
The California Resource Family Impact opposes this bill on
the grounds that the American Academy of Family Physicians
recommends vaccinations against the Human Papillomavirus
(HPV) for 11-year old girls. They believe that passage of
this bill will lead to the HPV vaccinations being mandated
for all girls. They believe that legislative intent is to
not support mandating HPV vaccines for girls, based on the
failure of AB 16 to become law.
PRIOR ACTIONS
Assembly Floor: 74-2
Assembly Appropriations:11-2
Assembly Health: 19-0
COMMENTS
1. State regulations for vaccines
According to DPH, additional vaccines can be required for
pupils in California either through statute or
regulation. Any vaccine may be added through statute.
Any vaccine recommended by ACIP and not otherwise limited
by H&S Code, Section 120335, may be added through
regulations promulgated by DPH after consultation with
the California Department of Education (CDE).
It is important to note that the bill itself does not
directly require DPH to implement a pertussis booster
shot prior to entering 7th grade. The bill seeks to
remove the stipulation that the pertussis vaccine can
only be required in children younger than seven (7) years
of age. By deleting this age restriction in statute, DPH
will have more flexibility through the regulatory process
in implementing childhood immunization schedules in the
state.
2. Suggested technical amendment
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On page 2, lines 22-24, amend as follows:
(10) Varicella (chickenpox). This paragraph shall be
operative only to the extent that funds for this purpose
are appropriated in the annual Budget Act.
POSITIONS
Support: American Academy of Pediatrics
American Federation of State, County, and Municipal
Employees
California Academy of Family Physicians
California Immunization Coalition
California Medical Association
California School Nurses Organization
California State PTA
GlaxoSmithKline
Oppose: Capitol Resource Family Impact
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