BILL ANALYSIS Ó
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Date of Hearing: June 9, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
277 (Pan and Allen) - As Amended May 7, 2015
SENATE VOTE: 25-11
SUBJECT: Public health: vaccinations.
SUMMARY: Eliminates non-medical exemptions 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. Specifically, this bill:
1)Deletes the exemption based on personal beliefs from the
existing immunization requirement for children in child care
and public and private schools. Deletes related law requiring
a form to accompany a personal belief exemption (PBE).
2)Exempts students enrolled in home-based private schools or in
an independent study program from the existing immunization
requirement.
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3)Permits the California Department of Public Health (DPH) to
add diseases to the immunization requirements only if
exemptions are allowed for both medical reasons and personal
beliefs.
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 diphtheria, Haemophilus influenzae type b
(Hib meningitis), measles, mumps, pertussis (whooping cough),
poliomyelitis, rubella (German measles), tetanus, hepatitis B,
and varicella (chickenpox).
2)Permits DPH to add to this list 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 Committee on Infectious Diseases.
3)Waives immunization requirements in 1) above, if the parent or
guardian files with the governing authority a written
statement by a licensed physician to the effect that the
physical condition of the child is such, or medical
circumstances relating to the child are such, that
immunization is not considered safe, indicating the specific
nature and probable duration of the medical condition or
circumstances that contraindicate immunization.
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4)Waives the above immunization requirements if the parent,
guardian, or an emancipated minor, files a letter with the
governing authority stating that the immunization is contrary
to his or her beliefs.
5)Requires a separate form prescribed by DPH to accompany a
letter or affidavit to exempt a child from immunization
requirements on the basis that an immunization is contrary to
beliefs of the child's parent or guardian. Requires the form
to include:
a) A signed attestation from the health care practitioner
that indicates that the parent, guardian, or emancipated
minor, was provided with information regarding the benefits
and risks of the immunization and the health risks of the
specified diseases to the person and to the community.
Requires the attestation to be signed not more than six
months before the date when the person first becomes
subject to the immunization requirement for which exemption
is being sought.
b) A written statement signed by the parent, guardian, or
emancipated minor, that indicates that the signer has
received the information provided by the health care
practitioner pursuant a) above. Requires the statement to
be signed not more than six months before the date when the
person first becomes subject to the immunization
requirements as a condition of admittance.
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6)Permits a local health officer to temporarily exclude from the
school or institution a child for whom the requirement has
been waived, whenever there is good cause to believe that he
or she has been exposed to one of the specified communicable
diseases, until the local health officer is satisfied that the
child is no longer at risk of developing the disease.
FISCAL EFFECT: None.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, in early
2015, California became the epicenter of a measles outbreak,
which spread in large part because of communities with large
numbers of unvaccinated people. According to the CDC, there
have been more cases of measles in January 2015 than in any
one month in the past 20 years. Between 2000 and 2012, the
number of PBEs from vaccinations required for school entry
that were filed rose by 337%. In 2000, the PBE rate for
kindergartners entering California schools was under 1%.
However, by 2013, that number rose to 3.15%. In certain
geographic pockets of California, exemption rates are 21% or
more, placing our communities at risk for the rapid spread of
entirely preventable diseases, according to the author. Given
the highly contagious nature of diseases such as measles,
vaccination rates of up to 95% are necessary to protect the
public health of the community and prevent future outbreaks.
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
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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. Vaccine 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.
Vaccine-preventable diseases have a costly impact, resulting
in doctor's visits, hospitalizations, and premature deaths.
Sick children can also cause parents to lose time from work.
CDC recommends routine vaccination to prevent 17
vaccine-preventable diseases that occur in infants, children,
adolescents, or adults.
In the U.S., the high vaccination rate for routinely
recommended immunizations for infant and childhood diseases
has brought about dramatic declines in the incidence of polio,
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measles, mumps, rubella, Haemophilus influenza type b,
hepatitis, and chickenpox. In the past decade,
recommendations for annual influenza vaccination have been
expanded to encompass all children six months to eighteen
years of age, and new vaccines have been added to the
immunization schedule to help protect infants from rotavirus
disease and adolescents from meningitis. As a result of the
advances in developing vaccines and including them as standard
of care, most diseases that are preventable by vaccination are
at record low levels in the U.S.
For years many of these diseases were thought to be ordinary
childhood experiences and many older adults had these diseases
as children. Nevertheless, they are serious deadly diseases
for some. For example, measles in children has a mortality
rate as high as about one in 500 among healthy children,
higher if there are complicating health factors.
In the past couple of decades, controversy has arisen about
vaccines and autism, the best number of injections to be
administered during a single visit or over the course of the
first years of life, and vaccine ingredients which has
prompted parents, the media, policy makers, and others to
raise concerns about the safety of recommended immunizations
as well as the vaccination schedule. Despite their positive
impact on health and well-being, vaccines have had a long
history of arousing anxiety. The rapid growth of the Internet
and social media has made it easier to find and disseminate
immunization-related concerns and misperceptions. According
to a 2011 study published in the journal Health Affairs,
results indicate that although the overwhelming majority of
parents surveyed intended to vaccinate their children fully, a
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majority of parents still had questions or concerns about
vaccines.
3)School IMMUNIZATION requirements. States enact laws or
regulations that require children to receive certain vaccines
before they enter childcare facilities and school, but with
some exceptions, including medical, religious, and
philosophical objections. School vaccination requirements are
thought to serve an important public health function, but can
also face resistance.
An article published in the 2001-02 Kentucky Law Journal
reviewed historical and modern legal, political,
philosophical, and social struggles surrounding vaccination
requirements. The authors stated that though school
vaccination has been an important component of public health
practice for decades, it has had a controversial history in
the U.S. and abroad. Historical and modern examples of the
real, perceived, and potential harms of vaccination,
governmental abuses underlying its widespread practice and
strongly held religious beliefs have led to fervent objections
among parents and other persons who object to vaccines on
legal, ethical, social, and epidemiological grounds. The
article states that public health authorities argue that
school vaccination requirements have led to a drastic decrease
in the incidence of once common childhood diseases. Those who
object to vaccines tend to view the consequences of mass
vaccination on an individualistic basis, focusing on alleged
or actual harms to children from vaccinations. As part of
their research, the authors compared childhood immunization
rates and rates of vaccine-preventable childhood diseases
before and after the introduction of school vaccination
requirements. The data suggest that school vaccination
requirements have succeeded in increasing vaccination rates
and reducing the incidence of childhood disease
Current state law mandates immunization of school-aged
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children against 10 specific diseases. Each of the 10
diseases was added to California code through legislative
action, after careful consideration of the public health risks
of these diseases, cost to the state and health system,
communicability, and rates of transmission. The Legislature
has a long history of thoughtful consideration for which
diseases pose the most serious health risks to the public.
Following is a brief summary of activity related to mandated
immunizations for children enrolling in school:
1889: School districts first allowed to exclude a student
who is not vaccinated against smallpox, and schools were
required to maintain a list of unvaccinated children (SB
92, Briceland, Chapter 24).
1961: Polio immunization added as a requirement, as well
as the first appearance of a philosophical exemption (AB
1940, DeLotto and Rumford, Chapter 837).
1977: Diphtheria, pertussis, tetanus, and measles were
added to immunization requirements for children entering
school (SB 942, Rains, Chapter 1176).
1979: Mumps and rubella were added to the list (AB 805,
Mangers, Chapter 435).
1992: Haemophilus influenzae type b was added (AB 2798,
Floyd, Chapter 1300, and AB 2294, Alpert, Chapter
1320).
1995 and 1997: Hepatitis B was added (AB 1194, Takasugi,
Chapter 291, Statutes of 1995 and AB 381, Takasugi,
Chapter 882, Statutes of 1997).
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1999: The Legislature voted to add Hepatitis A to the
list, but it was vetoed by Governor Davis (AB 1594,
Florez).
1999: Varicella was added to the list (SB 741, Alpert,
Chapter 747).
2007: The Legislature voted to add pneumococcus to the
list, but it was vetoed by Governor Schwarzenegger (SB
533, Yee).
2010: Tetanus, diphtheria and pertussis (TDaP) booster was
required for 7th graders (AB 354, Arambula, Chapter
434).
All of the diseases for which California requires school
vaccinations are very serious conditions that pose very real
health risks to children. Most of the diseases can be spread
by contact with other infected children. Tetanus does not
spread from student to student but because it is such a
serious potentially fatal disease, and it is easily
preventable by vaccine, the vaccination of children is
required prior to enrollment in school.
4)COMMUNITY IMMUNITY. 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
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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.
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 mask 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 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.
Studies find that when belief exemptions to vaccination
guidelines are permitted, vaccination rates decrease. An
analysis by the New York Times found that more than a quarter
of schools in California have measles-immunization rates below
the 92-94% recommended by the CDC. Research shows that people
with lower vaccine acceptance tend to group together in
communities. A study recently published in the journal
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Pediatrics found that schools with high PBE rates are
clustered in suburbs in the peripheral areas of California
cities. The same analysis found that schools with low
proportion of white students, or a high proportion of students
receiving free or reduced lunch, were more likely to have high
vaccination rates (less PBEs).
5)California measles outbreak. The authors point to an outbreak
of measles linked to Disneyland in in December 2014 as one of
the reasons for the introduction of this bill. This outbreak
led to 131 confirmed measles cases reported in California as
part of this outbreak. The outbreak, now declared over by
DPH, led to 19% of those infected requiring hospitalization.
The outbreak likely started from a traveler who became
infected overseas with measles, then visited the amusement
park while infectious; however, no source was identified.
Analysis by CDC scientists showed that the measles virus type
in this outbreak (B3) was identical to the virus type that
caused the large measles outbreak in the Philippines in 2014.
According to the CDC, measles is one of the first diseases to
reappear when vaccination coverage rates fall. In 2014, there
were over 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 Disney outbreak,
which is one of five outbreaks so far this year reported by
the CDC.
Of the confirmed cases, DPH reported:
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Forty-two cases visited Disneyland during December
17-20, 2014 where they are presumed to have been exposed
to measles;
Thirty-one are household or close contacts to a
confirmed case;
Fourteen were exposed in a community setting (e.g.,
emergency room) where a confirmed case was known to be
present;
Forty-four have unknown exposure source but are
presumed to be linked to the outbreak based on a
combination of descriptive epidemiology or strain type;
Five cases are known to have a different genotype
from the outbreak strain; and,
Among measles cases for whom DPH has vaccination
documentation, 57 were unvaccinated and 25 had 1 or more
doses of measles, mumps, and rubella (MMR) vaccine. A
number of those unvaccinated had a personal belief
exemption and also include many infants too young to be
vaccinated.
1)National Childhood Vaccine Injury Act. During the mid-1970s,
there was an increased focus on personal health and more
people became concerned about vaccine safety. Several
lawsuits were filed against vaccine manufacturers and
healthcare providers by people who believed they had been
injured by the TDaP vaccine. Damages were awarded despite the
lack of scientific evidence to support vaccine injury claims.
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In 1976, a preemptive attempt to conduct a nationwide
influenza vaccination campaign for the swine flu stoked
peoples' fears. The predicted epidemic did not occur and
there were some who argued this particular influenza vaccine
resulted in serious side effects.
As a result, potential liability costs and vaccine prices
soared, and several vaccine manufacturers halted production.
A vaccine shortage resulted and public health officials became
concerned about the return of epidemic disease.
To reduce liability and respond to public health concerns,
Congress passed the National Childhood Vaccine Injury Act
(NCVIA) in 1986. The NCVIA established the National Vaccine
Program Office (NVPO) to coordinate immunization related
activities among various federal agencies and requires health
care providers who give vaccines to provide an information
statement to the patient or guardian that contains a brief
description of the disease as well as the risks and benefits
of the vaccine. Additionally, the NCVIA requires health care
providers to report certain adverse health events following
vaccination to the Vaccine Adverse Event Reporting System
(VAERS). The VAERS system remains an important source of
information for the CDC and others to monitor the vaccine
program, but the system allows self-reporting by any citizen
or healthcare provider what they believe to be an adverse
vaccine-related event, but the event numbers publicly
available have not necessarily been medically verified or
scientifically studied. The National Vaccine Injury
Compensation Program (NVICP) was created to compensate those
injured by vaccines on a "no fault" basis. The NVICP has been
loudly criticized by some for inefficient operations, and for
providing legal immunity to the pharmaceutical industry.
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The NCVIA established a committee from the Institute of
Medicine (IOM) to review the literature on vaccine reactions.
This group concluded that there are limitations in our
knowledge of the risks associated with vaccines. The group
looked at 76 health problems to see if they were caused by
vaccines. Of those, 50 (66%) had no or inadequate research to
form a conclusion. The IOM identified several specific
problems, such as a limited understanding of biological
processes that underlie adverse events, incomplete and
inconsistent information from individual reports, poorly
constructed research studies (not enough people enrolled for
the period of time), inadequate systems to track vaccine side
effects, and few experimental studies were published in the
medical literature. The CDC states that in the time since the
publication of the IOM reports in the 1990s, significant
progress has been made to monitor side effects and conduct
research relevant to vaccine safety. In 2011 the IOM
published Adverse Effects of Vaccines: Evidence and Causality,
representing an extensive study of peer-reviewed vaccine
related research to date. The IOM Committee reviewed eight
vaccines given to children or adults (MMR, varicella,
influenza, hepatitis A, hepatitis B, human papillomavirus,
meningococcal, and DTP) and again found that vaccines are
generally very safe and that serious adverse events are quite
rare.
2)VACCINES AND AUTISM. The idea that autism is caused by
vaccination is influencing public policy, even though rigorous
studies do not support this hypothesis. The hypothesis is
based on the observation that the number of autism cases
increased in the 1980s, coinciding with a push for greater
childhood vaccinations, which increased above recommended
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levels children's exposure to mercury in the vaccine
preservative thimerosal. However, autism diagnosis continued
to rise even after thimerosal was removed from US childhood
vaccines in 2001. A review by the IOM of over 200 studies
concluded that that there was no causal link between
thimerosal-containing vaccines and autism. Other studies have
found that autism is no more common among vaccinated than
unvaccinated children.
3)Exemptions to vaccine requirements. There are currently
three types of exemptions to the requirement that children be
vaccinated before entering school: medical; religious; and,
philosophical.
a) A medical exemption letter can be written by a licensed
physician that believes that vaccination is not safe for
the medical conditions of the patient, such as those whose
immune systems are compromised, who are allergic to
vaccines, are ill at the time of vaccination, or have other
medical contraindications to vaccines for that individual
patient. Every state allows medical exemptions from school
vaccination requirements. This determination is entirely
up to the professional clinical judgment of the physician.
There are no required medical criteria for diagnosing
circumstances that contraindicate vaccination. A physician
must base that decision on their professional judgment and
the standard of practice for their field. According to the
Medical Board of California, the "standard of care" (or
"standard of practice") for general practitioners is
defined as that level of skill, knowledge and care in
diagnosis and treatment ordinarily possessed and exercised
by other reasonably careful and prudent physicians in the
same or similar circumstances at the time in question.
Specialists are held to the standard of skill, knowledge
and care ordinarily possessed and exercised by other
reasonably careful and prudent specialist in the same or
similar circumstances.
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b) Religious exemptions allow parents to exempt their
children from vaccination if it contradicts their sincere
religious beliefs. Many states allow religious exemptions
from school vaccination requirements, although states
interpret the enforcement of them differently. In some
states, a parent may simply attest that vaccinations are
against their religious beliefs, while in other states the
parent must show membership in a church, and that the
church's official policy is opposed to vaccination.
According to the National Conference of State Legislatures
(NCSL), as of June 2014, 48 states allow religious
exemptions (all but Mississippi and West Virginia).
c) Philosophical exemption, which is defined differently in
different states, generally means that the statutory
language does not restrict the exemption to purely
religious or spiritual beliefs. For example, Maine allows
restrictions based on "moral, philosophical or other
personal beliefs," and California allows objections based
on simply the parent(s) beliefs. According to NCSL, 20
states (Arizona, California, Colorado, Idaho, Louisiana,
Maine, Michigan, Minnesota, Missouri (limited to childcare
enrollees), New Mexico, North Dakota, Ohio, Oklahoma,
Pennsylvania, Texas, Utah, Vermont, Washington, West
Virginia, and Wisconsin) permit philosophic exemptions.
As of February, several state legislatures had introduced
bills that would address non-medical exemptions. In addition
to California, legislators in Oregon, Vermont, and Washington
proposed to remove philosophical/personal belief exemption
this year. The bills were tabled in Oregon and Washington.
On May 25, 2015, the Governor of Vermont signed legislation
removing philosophical exemptions, but not religious ones, in
that state.
4)SPECIAL EDUCATION. Pursuant to the federal Individuals with
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Disabilities Education Act (IDEA), children with disabilities
are guaranteed the right to a free, appropriate public
education, including necessary services for a child to benefit
from his or her education. Between 1976 and 1984, to meet
this federal mandate, California schools provided mental
health services to special education students who needed the
services pursuant to an Individualized Education Program
(IEP). An IEP is a legally binding document that determines
what special education services a child will receive and why.
IEPs include a child's classification, placement, specialized
services, academic and behavioral goals, a behavior plan if
needed, percentage of time in regular education, and progress
reports from teachers and therapists. A child may require any
related services in order to benefit from special education,
including (but not limited to): speech-language pathology and
audiology services, early identification and assessment of
disabilities in children, medical services, physical and
occupational therapy, orientation and mobility services; and
psychological services.
According to the California Department of Education (CDE),
over 700,000, or approximately 11% of, California students
received Special Education services in the 2013-14 academic
year.
5)Independent Study. April 22, 2015 amendments to this bill
exclude pupils who are enrolled in an independent study
program from the immunization requirements of the bill.
Independent study is an optional educational alternative,
available to students from kindergarten through high school
that is meant to respond to the student's specific educational
needs, interests, aptitudes, and abilities. Independent study
is an alternative to classroom instruction consistent with a
school district's regular course of study and is expected to
be equal or superior in quality to classroom instruction.
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Each school district can develop Independent Study options in
its own way. Parents and students may also develop
alternative forms of independent study and propose them to the
school board. The options are based on the kinds of students
being served. The following are some of the ways in which
independent study is organized:
a) School-within-a-school;
b) District or county alternative in a community location;
c) School-based independent study offered part-time and
full-time;
d) Countywide home-based independent study offered by the
county superintendent of schools;
e) District dropout prevention centers at selected
community sites;
f) Curricular enrichment options offered to high school
students with special abilities and interests, scheduling
problems, or individual needs that cannot be met in the
regular program;
g) Alternative school-based independent study, on-or
off-site; and,
h) Some combination of the above.
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Independent study can be operated on a traditional school
calendar, with a summer school option for eligible students,
or on a year-round calendar within a year-round school.
Students must have the option of a classroom setting for a
full program at the time independent study is made available.
This option must be continuously available the student decide
to transfer from independent study. The classroom setting
option can be offered by the county office of education if the
district and county have a formal agreement that has the
effect of providing the student with a program that is
equivalent to what is offered in the school of residence.
a) Seat Time / Average Daily Attendance. Participation in
independent study must be voluntary. For students
participating in independent study, a contractual agreement
is drawn among the certificated teacher, the student, and
his or her parent, guardian, or caregiver. Attendance
records are based on a student's work within the terms and
conditions of his or her written agreement and not on
traditional "seat-time." In independent study, the
student's performance, measured by the terms in the
agreement, is converted by the supervising teacher into
school days. The computed school days are reported as if
the student were physically in attendance.
b) Legal Enrollment Restrictions. California education law
mandates the following for the administration of
independent study programs:
i) No pupil shall be required to participate in
independent study;
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ii) Not more than 10% of the students enrolled in an
opportunity school or program, or a continuation high
school, shall be eligible for independent study. A
student who is pregnant or is a parent and primary
caregiver for one or more of his or her children shall
not be counted within the 10% cap;
iii) No individual with exceptional needs may participate
in independent study unless his or her IEP specifically
provides for that participation; and,
iv) No temporarily disabled pupil may receive individual
instruction. However, if the temporarily disabled
pupil's parents and the district(s) agree, the pupil may
receive instruction through independent study instead of
the "home and hospital" instruction.
c) Enrollment History. According to CDE, in 2013-14 there
were approximately 122,000 independent study students
reported by charter schools and 34,000 reported by school
districts. Independent study enrollment was not collected
for the 2009-10 and 2010-11 school years. In October 2008,
data collected from schools reported that 128,000 students
in kindergarten through grade twelve were enrolled in
independent study.
6)Legal Considerations. Courts have determined that the family
itself is not beyond regulation in the public interest and
neither rights of religion nor rights of parenthood are beyond
limitation. As discussed at length in the Senate Judiciary
Committee analysis, extensive case law establishes that the
police powers of the state may restrict the parent's control
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in many ways, such as requiring school attendance and
regulating or prohibiting the child's labor. This authority
is not nullified because the parent grounds his claim to
control the child's course of conduct on religion or
conscience. Thus, a parent cannot claim freedom from
compulsory vaccination for their child more than for himself
on religious grounds. The right to practice religion freely
does not include liberty to expose the community or the child
to communicable disease or the latter to ill health or death.
For a further discussion of the legal rights and ramifications
of this bill, please see the Senate Judiciary Committee
Analysis as published on April 28, 2015.
7)SUPPORT. The Superintendent of Public Instruction (SPI), Tom
Torlakson, supports this bill, stating that school and child
care immunization requirements have proven effective in
increasing immunization rates, limiting the spread of disease,
and providing an overall public health benefit. He further
states that California has seen a dramatic increase in the PBE
rate for students entering kindergarten over the past fifteen
years, placing other children, and the overall public health
of our citizens, at risk of illness or death from preventable
diseases. The SPI concludes that education is a fundamental
right in California, and this bill provides education choices
for families opting not to vaccinate their children.
The California Medical Association, a cosponsor of this bill,
states that in 2000, the CDC determined that measles had been
eradicated in the U.S. However, since December 2014,
California has had 136 confirmed cases of measles across
fourteen counties. Almost 20% of those cases have required
hospitalization. Efforts to contain the outbreak have
resulted in mandatory quarantines and the redirection of
public health resources to investigations into exposure. The
California Immunization Coalition, writing in support of this
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bill, notes that in the 2013-14 school year more than 16,800
kindergarteners in California started school with either no
vaccinations or only some of their required vaccinations
because their parent had chosen to exempt them from
vaccinations, representing a 25% increase over the previous
two school years.
March of Dimes Foundation and the Medical Oncology Association
of Southern California, Inc. state that public participation
in immunization programs is critical to their effectiveness.
Protection is greatly affected by rates of immunization: the
more people immunized, the less the risk of exposure to, and
illness from, vaccine-preventable infections.
The Medical Board of California states that vaccines have been
scientifically proven to be effective in preventing illnesses.
Ensuring that children receive the ACIP recommended
vaccination schedule is the standard of care, unless there is
a medical reason that the child should not receive the
vaccine; this bill would still allow for a medical exemption
to address these concerns. The Children's Specialty Care
Coalition notes that high vaccine coverage, particularly at
the community level, is extremely important for people who
cannot be vaccinated, including people who have medical
contraindications to vaccinations and those who are too young
to be vaccinated. Protecting the individual and the community
from communicable diseases such as measles, mumps, and
pertussis, is important to the public's health.
The Committee notes it has received hundreds of letters in
support of this bill. Many letters from individuals in
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support write to raise similar points regarding reductions in
vaccination rates for school children, recent dangerous
measles and pertussis outbreaks, concerns for the health of
children and medically fragile individuals, and concerns for
the safety of communities at large.
8)OPPOSITION. Opponents state that this bill is an extreme
measure that is not necessary at this time. The California
Chiropractic Association states that this bill proffers the
notion that health officials will be given the power to
nullify the doctor-patient relationship, and veto the judgment
of any physician who questions the status quo and believes
that a patient should not receive a particular vaccine. A
Voice for Choice states that the Legislature should look to
alternative approaches that will stop the transmission of
disease and continue to allow parents to work with their
doctors for the best vaccination schedule for their individual
children, and allow their children their constitutional right
to a free and public education.
The Committee also notes that it received hundreds of letters
in opposition to this bill. A letter from Our Kids Our Choice
and many other similar letters argue that the bill removes
federally mandated rights of services to students with
disabilities under the federal IDEA. This group, like many
others, points to the NVIC and the fact that the U.S.
government "has paid out more than $3 billion to the victims
of vaccine injury" as support for why medical choice is
appropriate. "If there is risk of injury or death there must
be a choice." In contrast, they argue that "vaccination rates
of California schoolchildren are high at 98.64%" and cite the
success of recent legislation, AB 2109 (Pan), Chapter 821,
Statutes of 2012, which they say has resulted in a 19%
decrease in exemptions amongst kindergarteners in just one
year. They argue the public health concerns are already
adequately addressed with current California laws. Many
letters from individuals write to raise relatively similar
points regarding various constitutional rights, informed
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consent, vaccine safety/injuries, absence of a health crisis,
lack of educational choice, difficulty in obtaining medical
exemptions, and the like.
ParentalRights.Org states that "?while we appreciate the
intent of the amendment to exempt homeschoolers from the
vaccination requirement, it is not sufficient to protect the
rights of parents and children in California. While there are
many parents with strong convictions that the risks of
vaccines to their child (as reflected in lengthy disclaimers
which accompany these products) outweigh the potential
benefits, many of these same parents are also deeply convinced
that the best educational opportunity they can provide their
child is in the public schools. These parents should not be
forced to give up their rights in one area to exercise their
rights in another. No child should have to forego the best
available education for the sake of his best health, nor give
up his best health for the sake of a better education."
9)CONCERNS. American Civil Liberties Union of California
(ACLU-CA) states that "while we appreciate that vaccination
against childhood diseases is a prudent step that should be
promoted for the general welfare, we do not believe there has
been a sufficient showing of need at present to warrant
conditioning access to education on mandatory vaccination for
each of the diseases covered by this bill for every school
district in the state." ACLU-CA further states that unlike
other states where a vaccination mandate may be more
permissible, public education is a fundamental right under the
California Constitution. Equal access to education must
therefore not be limited or denied unless the State
demonstrates that its actions are "necessary to achieve a
compelling state interest." The California Association of
Private School Organizations states that that association has
taken no formal position on the measure, and does not oppose
the elimination of the PBEs, they are concerned about the
increased administrative burden to which schools will be
subjected should this bill become law. The association urges
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amendments that would create a phase-in period, lengthen the
time horizon for compliance as per the existing regulations,
or enact such other provisions as may produce a combination of
increased compliance and a decreased possibility of mandatory
exclusion.
10)RELATED LEGISLATION. SB 792 (Mendoza) prohibits a person
from being employed at a day care center or day care home
unless he or she has been immunized against influenza,
pertussis, and measles. SB 792 was approved by the Senate on
May 22, 2015 by a vote of 34-3 and is currently pending
committee referral in the Assembly.
11)PREVIOUS LEGISLATION.
a) AB 2109 requires, on and after January 1, 2014, a
separate form prescribed by DPH to accompany a letter or
affidavit to exempt a child from immunization requirements
under existing law on the basis that an immunization is
contrary to beliefs of the child's parent or guardian.
Required the form to include:
i) A signed attestation from the health care
practitioner that indicates that the parent or guardian
of the person who is subject to the immunization
requirements, the adult who has assumed responsibility
for the care and custody of the person, or the person if
an emancipated minor, was provided with information
regarding the benefits and risks of the immunization and
the health risks of the communicable diseases listed
above to the person and to the community.
ii) A written statement signed by the parent or guardian
of the person who is subject to the immunization
requirements, the adult who has assumed responsibility
for the care and custody of the person, or the person if
an emancipated minor, that indicates that the signer has
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received the information provided by the health care
practitioner pursuant to i) above.
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."
b) SB 614 (Kehoe, Chapter 123, Statutes of 2011) allows a
pupil in grades seven through 12, to conditionally attend
school for up to 30 calendar days beyond the pupil's first
day of attendance, if that pupil has not been fully
immunized with all pertussis boosters appropriate for the
pupil's age if specified conditions are met.
c) AB 354 (Arambula, Chapter 434, Statutes of 2010) allowed
DPH to update vaccination requirements for children
entering schools and child care facilities and added the
American Academy of Family Physicians to the list of
entities whose recommendations DPH must consider when
updating the list of required vaccinations. Requires
children entering grades seven through 12 receive a TDaP
booster prior to admittance to school.
d) SB 1179 (Aanestad, 2008) would have deleted DPH's
authority to add diseases to the list of those requiring
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. SB 1179 died in Senate Health
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Committee.
12)POLICY COMMENTS.
a) Collecting complete data will provide an accurate
picture of partial vaccination rates throughout the state.
To date, we do not have an exact picture of the vaccination
status of every student in California. For the 2014-15
school year, less than 95% of schools reported their
vaccination numbers to DPH. Of the schools reporting, DPH
found that 90.4% of enrolled kindergarteners had received
the complete vaccination schedule. Additionally 6.9% of
students were conditionally enrolled because they were
lacking some immunizations, and were in the process of
completing the required vaccination schedule. For the
2014-15 school year, DPH calculated individual antigen
vaccination status (such as DTP, Polio, MMR, etc) based
only on the number of fully vaccinated students and
vaccinations completed by conditionally enrolled students.
DPH did not include in this calculation the individual
antigen status for partially vaccinated students with PBEs.
Therefore, it is likely that individual antigen
immunization coverage may be underestimated. Anecdotal
evidence suggests that some percentage of students have
some, but not all, required immunizations.
DPH is currently developing new regulations that will
implement complete data collection for partially vaccinated
students holding PBEs and medical exemptions. This will
ensure that reported data are a more accurate reflection of
the vaccination rate for each immunization.
b) Identification of partially and non-vaccinated students.
Current law requires that parents filing a PBE must
provide the school with documentation for "which
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immunizations have been given and which immunizations have
not been given on the basis that they are contrary to his
or her beliefs" for the purposes of immediate
identification in case of disease outbreak in the
community. As drafted, this requirement would be deleted
by SB 277. If SB 277 is enacted, schools will still need
to know which specific immunizations have or have not been
received by all students, including those that are enrolled
in independent study. The author may wish to take an
amendment to clarify that schools will collect information
for all enrolled students, regardless of immunization
status.
13)SUGGESTED AMENDMENTS.
a) A physician's professional judgment. As previously
discussed, it is entirely within the professional judgment
of a physician to determine if vaccination is not
recommended due to the medical history of the patient.
Opponents of this bill have raised concerns that current
law regarding the letter of medical exemption does not
adequately make clear that the letter may be written based
on the best medical judgment of the physician. To that
end, the author may wish to consider amending this bill.
Section 120370. (a)If the parent or guardian files with
the governing authority a written statement by a licensed
physician to the effect that the physical condition of
the child is such, or medical circumstances relating to
the child are such, that immunization is not considered
safe, indicating the specific nature and probable
duration of the medical condition or circumstances that
contraindicate for which the physician does not recommend
immunization, that child shall be exempt from the
requirements of Chapter 1 (commencing with Section
120325, but excluding Section 120380) and Sections
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120400, 120405, 120410, and 120415 to the extent
indicated by the physician's statement.
b) Implementation clarification clause. As discussed in
the Senate Judiciary Committee analysis, clarification is
needed to address the status of students currently enrolled
with an existing PBE upon the operative date of this bill.
Section 120335 (g) The governing authority shall allow
continued enrollment to pupils who, prior to January 1,
2016, have a letter or affidavit on file in that
institution stating beliefs opposed to immunization. On
and after July 1, 2016, the governing authority shall not
unconditionally admit to that institution for the first
time or admit or advance any pupil to the 7th grade level
unless the pupil has been immunized as required by this
section.
c) Special education students must have access to services.
As previously discussed, under federal and state law
disabled children are guaranteed the right to a free,
appropriate public education, including necessary services
for a child to benefit from his or her education. An
amendment should be taken to clarify that students with an
IEP will still have access to special education related
services as directed by their IEP.
Section 120335 (h) Nothing in this section shall
prohibit a pupil that qualifies for an individualized
education program, pursuant to federal law and Section
56026 of the Education Code, from accessing any special
education and related services required by their
individualized education program.
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d) Independent study programs are highly variable. As
previously discussed, students enrolled in an independent
study program are excluded from the provisions of this bill
requiring them to be vaccinated. Independent study courses
take many forms and in many places, including both on and
off school sites. As currently drafted, there is nothing
differentiating classroom based versus non-classroom based
independent study instruction. An amendment should be
taken to specify that students enrolled in off-campus
independent study are not subject to vaccination
requirements.
Section 120335 (f):This section does not apply to a pupil
in a home-based private school or a pupil who is enrolled
in an independent study program pursuant to Article 5.5
(commencing with Section 51745) of Chapter 5 of Part 28
of the Education Code and does not receive
classroom-based instruction.
REGISTERED SUPPORT / OPPOSITION:
Support
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California Immunization Coalition (cosponsor)
California Medical Association (cosponsor)
Vaccinate California (cosponsor)
Dave Jones, California Insurance Commissioner
Katie Rice, Supervisor, Marin County
Sheila Kuehl, Los Angeles County Supervisor and former State
Senator
Tom Torlakson, California Superintendent of Public Instruction
AIDS Healthcare Foundation
Alameda County Board of Supervisors
Albany Unified School District
American Academy of Pediatrics - California
American College of Emergency Physicians California Chapter
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American Federation of State, County and Municipal Employees,
AFL-CIO
American Lung Association
American Nurses Association\California
Association of California School Administrators
Association of Northern California Oncologists
BIOCOM
California Academy of Family Physicians
California Academy of Physician Assistants
California Association for Nurse Practitioners
California Association of Physician Groups
California Black Health Network
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California Children's Hospital Association
California Coverage and Health Initiatives
California Department of Insurance
California Disability Rights, Inc.
California Healthcare Institute
California Hepatitis Alliance
California Hospital Association
California Immunization Coalition
California Optometric Association
California Pharmacists Association
California Primary Care Association
California Public Health Association-North
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California School Boards Association
California School Employees Association
California School Nurses Organization
California State Association of Counties
California State PTA
Carlsbad High School Parent-Teacher-Student Association
Child Care Law Center
Children Now
Children's Defense Fund California
Children's Healthcare Is a Legal Duty, Inc.
Children's Hospital Oakland
Children's Specialty Care Coalition
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City and County of San Francisco Board of Supervisors
City of Berkeley
City of Beverly Hills
City of Pasadena
Contra Costa County
County Health Executives Association of California
County of Marin
County of Tehachapi
Democratic Women's Club of Santa Cruz County
Donate Life California
First 5 California
Foundation for Pediatric Health
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Gilroy Unified School District
Health Officers Association of California
Jay Hansen, Sacramento County School Board Member
Junior Leagues of California
Kaiser Permanente
Los Angeles Community College District
Los Angeles County Board of Supervisors
Los Angeles County Supervisor Sheila Kuehl
Los Angeles Unified School District
March of Dimes California Chapter
Medical Board of California
Medical Oncology Association of Southern California
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MemorialCare Health System Physician Society
National Coalition of 100 Black Women Sacramento Chapter
Osteopathic Physicians and Surgeons of California
Pasadena Public Health Department
Project Inform
Providence Health and Services, Southern California
Reed Union School District
San Dieguito Union High School District
San Francisco Democratic County Central Committee
San Francisco Unified School District
Santa Clara County Board of Supervisors
Santa Cruz County
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Santa Cruz County Democratic Party
Santa Monica Malibu Union Unified School District
School for Integrated Academics and Technologies, California
Secular Coalition for California
Silicon Valley Leadership Group
Solano Beach School District
Sonoma County Board of Supervisors
The Children's Partnership
UAW Local 5810, University of California Postdoctoral
Researchers
University of California Hastings College of the Law
University of California, Irvine Center for Virus Research
University of California, Irvine School of Medicine
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Yolo County Board of Supervisors
Numerous Medical Doctors
Numerous Osteopathic Doctors
Numerous health care professionals, including RNs, PAs and NPs
Hundreds of individuals
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Opposition
A Voice for Choice
Alliance of California Autism Organizations
Association of American Physicians and Surgeons (Tucson, AZ)
APLUS+ Network Association
Autism Society
AWAKE California
California Chiropractic Association
California Coalition for Health Choice
California Naturopathic Doctors Association
California Nurses for Ethical Standards
California Nurses for Ethical Standards
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California ProLife Council
California Right to Life Committee, Inc.
Canary Party
Capitol Resource Institute
Educate. Advocate.
Educate. Advocate.
Faith and Public Policy
Families for Early Autism Treatment
Foundation for Pediatric Health
Gold Mine Natural Food Co.
Homeschool Association of California
HSC Homeschool Association of California
National Autism Association California
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National Vaccine Information Center
Our Kids, Our Choice
Pacific Justice Institute
Pacific Justice Institute Center for Public Policy
ParentalRights.Org
Pediatric Alternatives
SafeMinds
Saint Andrew Orthodox Christian Church
Standing Tall Chiropractic: A Creating Wellness Center
Unblind My Mind
Vaccine Choice Canada (Winlaw, British Columbia)
Vaccine-Injury Awareness League
Weston A. Price Foundation
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Numerous Chiropractors
Numerous Medical and Osteopathic Doctors
Hundreds of individuals
Analysis Prepared by:Dharia McGrew and Paula Villescaz / HEALTH
/ (916) 319-2097