BILL ANALYSIS �
SB 614
Page 1
Date of Hearing: July 11, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 614 (Kehoe) - As Amended: July 1, 2011
SENATE VOTE : Not relevant.
SUBJECT : Childhood immunization.
SUMMARY : Delays, from July 1, 2011 to January 1, 2012, the
requirement that a pupil of any private or public elementary or
secondary school be fully immunized against pertussis, including
all pertussis boosters appropriate for the pupil's age, before
he or she can be admitted or advanced in the 7th through 12th
grades. Makes a technical, clarifying change. Contains an
urgency clause to ensure that the provisions of this bill go
into immediate effect upon enactment.
EXISTING LAW :
1)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 has been fully
immunized against the following diseases: diphtheria;
haemophilus influenzae type b; measles; mumps; pertussis;
poliomyelitis; rubella; tetanus; hepatitis B; varicella
(chickenpox); and, any other disease deemed appropriate by the
Department of Public health (DPH), taking into consideration
the recommendations of the Advisory Committee on Immunization
Practices of the United States (US) Department of Health and
Human Services, the American Academy of Pediatrics, and the
American Academy of Family Physicians (AAFP).
2)Prohibits, effective July 1, 2011, governing authorities from
unconditionally admitting or advancing any pupil to the 7th
through 12th grades of any private or public elementary or
secondary school unless the pupil has been fully immunized
against pertussis, including all pertussis boosters
appropriate for the pupil's age.
3)Waives the requirements in 1) and 2) above for medical reasons
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or if the parent, guardian, or adult who has assumed
responsibility for the child files a letter or affidavit with
the school governing authority stating that the immunization
is contrary to his or her beliefs.
4)Permits a child who has had an immunization requirement
waived, whenever there is good cause to believe that the
person has been exposed to one of specified communicable
diseases, to be temporarily excluded from the school or
institution until the local health officer is satisfied that
the person is no longer at risk of developing the disease.
5)Requires county health officers to organize and maintain a
program to make immunizations available to all persons
required to be immunized as specified under 2) above and other
specified statutes, and specifies that counties shall pay
costs that are not recovered from persons immunized.
FISCAL EFFECT : None
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, dozens of
school districts have reported that pupil compliance with the
July 1, 2011 pertussis immunization requirements is alarmingly
low in many districts. The author states that districts from
urban, suburban and rural areas stand to lose substantial
state funding because high percentages of pupils in those
districts have yet to be immunized as required. The author
contends that over 20 school districts will lose over $100,000
per day while San Diego Unified School District (USD) will
lose over $1 million per day and Los Angeles USD estimates
that approximately half of its 250,000 7th through 12th
graders still need the vaccination. The district forecasts
that it would amounts to a $3.4 million daily loss in revenue
if all of those students were turned away. The author states
that districts are also concerned about unknown public health
and public safety impacts if students are not allowed to
attend school and must otherwise occupy their time.
2)BACKGROUND . According to the US Centers for Disease Control
and Prevention (CDC), pertussis (also known as whooping
cough), is a highly contagious respiratory disease that is
known for uncontrollable, violent coughing which often makes
it hard to breathe. After fits of many coughs, someone with
pertussis often needs to take deep breaths which result in a
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"whooping" sound. Pertussis most commonly affects infants and
young children and can be fatal, especially in babies less
than one year of age. In infants younger than one year of age
who get pertussis, more than half must be hospitalized. Of
those infants who are hospitalized with pertussis, about one
in five get pneumonia, half will have apnea (slowed or stopped
breathing), one in 300 will have encephalopathy (disease of
the brain); and one in 100 will die. According to the CDC,
the incidence of pertussis is cyclical, with peaks occurring
every three to five years in the US. The last peak was in
2005, when approximately 25,000 cases were reported nationally
and approximately 3,000 cases in California, including eight
deaths in infants under three months of age. According to
DPH, peak months for pertussis in California and the US are
typically summer and fall. We do not know yet how severe the
peak seasons will be in 2011.
3)CALIFORNIA OUTBREAK . In 2010, DPH saw a substantial increase
in the number of pertussis cases reported. According to a
report from the CDC, from January 1 to June 30, 2010, a total
of 1,337 cases were reported in California, which was a 418%
increase from the 258 cases reported during the same period in
2009. From January to June that year, the incidence of
pertussis was 3.4 cases per 100,000 population. County rates
ranged from zero to 76.9 cases per 100,000. By age group,
incidence was highest (38.5 cases per 100,000) among infants
aged less than one year; 89% of cases were among infants under
six months, who are too young to be fully immunized.
Incidence among children aged seven to nine years was 10.1
cases per 100,000 and for 10 to 18 years old it was 9.3 cases
per 100,000, respectively. Incidence among Latino infants
(49.8 cases per 100,000) was higher than among other
racial/ethnic populations. According to DPH, there were 10
deaths resulting from pertussis infection in 2010. According
to the DPH's April 2011 Pertussis Report, disease activity in
2011 is still at relatively increased levels throughout the
state with 733 cases reported through March 2011 (23.7 cases
per 100,000).
4)PERTUSSIS VACCINE . According to the CDC, the best way to
prevent pertussis is to get vaccinated. In the US, the
recommended pertussis vaccine for infants and children is
called DTaP, which is a combination vaccine that protects
against three diseases: diphtheria; tetanus; and, pertussis.
For maximum protection against pertussis, children need five
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DTaP shots. The first three shots are given at two, four, and
six months of age. The fourth shot is given between 15 and 18
months of age, and a fifth shot is given before a child enters
school, at four to six years of age. Parents can also help
protect infants by keeping them away as much as possible from
anyone who has cold symptoms or is coughing. Vaccine
protection for pertussis, tetanus, and diphtheria fades with
time. Before 2005, the only booster available contained
protection against tetanus and diphtheria, and was recommended
for teens and adults once every 10 years. There are boosters
for pre-teens, teens and adults that contain protection
against tetanus, diphtheria, and pertussis. It is recommended
that pre-teens going to the doctor for their regular check-up
at age 11 or 12 years get a dose, and teens who did not get
this vaccine at the 11- or 12-year-old check-up get vaccinated
at their next visit. Adults who did not get the booster as a
pre-teen or teen should get a dose. Pregnant women who had
not previously received the booster shot should get one
postpartum before leaving the hospital or birthing center.
Adults 65 years and older (grandparents, child care providers,
and healthcare providers) who have close contact with infants
should get vaccinated. According to DPH, the two
manufacturers of the US Food and Drug Administration licensed
pertussis booster vaccine have stated that that they are
making ample supplies of Tdap vaccine, the booster for DTaP
(as well as of the DTaP vaccine which has been required for
many years for children entering kindergarten).
5)COMPLIANCE WITH JULY 1 REQUIREMENT . According to a survey of
68 local education agencies (LEAs) conducted by the California
Association of School Business Officials (CASBO), compliance
to the July 1 pertussis booster requirement varies fairly
significantly. Rates of compliance range from lows of 20%
�Las Virgenes Unified School District (USD), serving the
communities of Agoura, Agoura Hills, Calabasas, Hidden Hills,
and Westlake Village], 25% �Pajaro Valley USD in
Watsonville/Aptos], and 30% �Central Union SD, serving
Lemoore, Stratford, and the Lemoore Naval Air Station], to as
high as 80% �Brentwood Union in Contra Costa County], 85% �La
Habra City School District in northwestern Orange County and
Lindsay USD in Tulare county], and 95% �CoronaNorco USD in
western Riverside County and Farmersville USD Tulare County].
Los Angeles USD has 250,000 pupils in 7th through 12th grades,
half of whom have had the Tdap booster.
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6)SUPPORT . CASBO states that as schools acted throughout the
spring to urge parents to get their students vaccinated
pursuant to the July 1, 2011 requirement, it became clear that
a significant portion of the population would not make the
deadline. CASBO states that in many areas of the state, more
than half of the students have yet to show proof of
vaccination, and that more time is needed to ensure that
students and parents are able to get the vaccination and
paperwork that confirms the vaccination without those students
losing valuable classroom time. Numerous school districts
write that despite extensive district outreach over the past
six months, including public education campaigns, parent
contacts, and school -sponsored clinics, it is now clear that
a significant number of next year's incoming grade 7-12
students are not yet immunized. These school districts state
that with summer vacation now underway, their ability to reach
families of non-immunized students is severely diminished.
The San Diego USD (SDUSD) writes that since schools receive
state funding based on attendance, turning away students will
result in the loss of up to $1 million per day in funding for
SDUSD schools. SDUSD states that this loss of funds would
severely set back their ability to deliver educational
programs to students, and may result in serious mid-year cuts.
Further, SDUSD writes that the unattainable current deadline
may also have negative health impacts as some families who
find it difficult to get their students immunized quickly may
sign personal belief waivers just to keep their students in
school - which could undermine the very purpose of the
pertussis immunization requirement. Other supporters write
that an extension is in the best interest of students because
a more realistic timeframe will allow schools, providers, and
local public health entities to work together to ensure
complete immunization and students will be less likely to be
excluded from school. Supporters are concerned that the
current timeframe will cause parents to seek waivers and
possibly never have their children immunized.
7)OPPOSE . The Health Officers Association of California (HOAC)
writes that a 2009 Dutch study shows (and data from the CDC
also suggests) that pertussis peaks in the early fall and that
in order to prevent transmission at this crucial time, it is
important to immunize children before they return to the
classroom. HOAC asserts that extending the deadline as
proposed by this bill will result in increased opportunity for
transmission and will not adequately protect California's
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children from this potentially fatal disease. HOAC states that
school districts have had since September of 2010 to prepare
for the July 1 requirement and while they expect that there
will be delays and complications during any worthwhile effort,
California is still dealing with this record breaking epidemic
and HOAC believes it would be misguided to extend the
important and well-reasoned deadline beyond July 1.
8)OPPOSE UNLESS AMENDED . The American Academy of Pediatrics,
California (AAP-CA), writes that whenever there is a new
vaccine requirement there is some challenge in educating
families, as well as for those families to find time in their
busy lives to get the vaccine. AAP-CA states that as a
result, vaccination compliance often happens last minute, and
only when there is a consequence of inability to attend
school. AAP-CA states that delaying the pertussis requirement
until January 1, 2012 is therefore only likely to push the
problem of compliance back, rather than eliminate it and that
further, during those months of proposed delay, infants would
remain at increased risk of hospitalization and death since
pertussis peaks in late summer and early fall. AAP-CA writes
that one argument for delaying the requirement is that it
would be easier for schools to get the message to teens and
families and to enforce the law when the students are already
in daily attendance at the school. For that reason, AAP-CA
would support an amendment to the bill that would remove the
delay to January 1, 2012, and substitute instead a grace
period of 30 days after the first day of school during which
preteens and teens may attend school without providing
evidence of their booster vaccine for pertussis. AAP-CA states
that 30 days after the first day of school would therefore be
the firm deadline for them to have the vaccine.
9)CONCERNS . The California Immunization Coalition (CIC) states
that the current momentum and sense of urgency that we have
been working to convey to parents and the media will be
lessened by the extension proposed under this bill. CIC
states that AB 354 (Arambula), Chapter 434, Statutes of 2010,
which created the July 1, 2011 deadline, was signed on
September 29, 2010, and early alerts went out to schools,
health care providers and local health departments within
weeks and all have been notifying parents since the beginning
of 2011 via phone calls, fliers, and e-mails. CIC asserts
that shifting the deadline to January 1, 2012 will likely
impact the messaging when the law shifts to only require 7th
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grade students to show proof of Tdap vaccination, which may
cause confusion as to who is required to be immunized and
when. CIC further states that there would be significant
administrative costs to DPH to re-notice school districts,
health care providers and health plans about the change
proposed in this bill. CIC asks for an amendment to provide a
30-day grace period for students to bring proof of Tdap
vaccination after the school start date. CIC states that this
would provide flexibility for schools to base their timeline
on the individual school start dates and offers some relief
for parents and students to obtain proof of vaccine without
drawing out the task for schools to monitor and follow up for
six months.
10)RELATED LEGISLATION . AB 1192 (Garrick) requires DPH to make
available on its Internet Website specified information
related to the pertussis vaccine for use by hospitals.
Permits hospitals to distribute this information to the
parents of newborn children. This bill was heard, but not
voted on, in the Assembly Health Committee on April 29, 2011.
11)PREVIOUS LEGISLATION . AB 354, in addition to requiring that
children entering 7th through 12th grades receive a Tdap
booster prior to admittance to school, permits DPH to update
vaccination requirements for children entering schools and
child care facilities and adds AAFP to the list of entities
whose recommendations DPH must consider when updating the list
of required vaccinations.
AB 2580 (Arambula) of 2008 was similar to AB 354, but would
also have required pupils entering the 7th grade to be fully
immunized against pertussis by receiving any necessary
adolescent booster immunization. AB 2580 was held on the
Senate Appropriations Committee Suspense File.
REGISTERED SUPPORT / OPPOSITION :
Support
California Association of School Business Officials (sponsor)
Riverside County School Superintendents' Association (sponsor)
San Diego Unified School District (sponsor)
California Association of Suburban School Districts (sponsor)
Association of California School Administrators
California School Boards Association
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California School Health Centers Association
Central Valley Education Coalition
Children Now
Clovis Unified School District
Elk Grove Unified School District
Elsie Allen Health Center
Fresno Unified School District
Hemet Unified School District
Irvine Unified School District
Jurupa Unified School District
Long Beach Unified School District
Los Angeles County Office of Education
Los Angeles Unified School District
Monterey County Office of Education
Newport-Mesa Unified School District
Oakland Unified School District
Roseland Children's Health Center
Sacramento City Unified School District
Santa Cruz City Schools
Small School Districts' Association
Temecula Valley Unified School District
Opposition
Health Officers Association of California
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097