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california legislation > AB 2109

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Date of Hearing: April 17, 2012

ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 2109 (Pan) - As Introduced: February 23, 2012

SUBJECT
: Communicable disease: immunization exemption.

SUMMARY : Makes changes to existing requirements which allow
school-aged children, as specified, to be exempt from
immunization requirements as long as a parent or a guardian
files a letter or affidavit to the governing authority
indicating that immunization is contrary to the parent or
guardian's beliefs. Specifically, this bill :

1) Requires, on and after July 1, 2012, a separate form
prescribed by the California Department of Public Health
(DPH), to accompany the letter or affidavit to exempt a
child, as specified, from required immunization
requirements because immunization is contrary to the
child's parent's or guardian's beliefs.

2) Requires the form in 1) above to include both of the
following:

a) A written statement signed by a health care practitioner
that indicates that the health care practitioner provided
the parent or guardian of the person, or the person if an
emancipated minor, who is subject to the immunization
requirements, with information regarding the benefits and
risks of the immunization and the health risks of the
communicable diseases, as specified, to the person and to
the community; and,

b) A written statement signed by the parent or guardian of
the person, or the person if an emancipated minor, who is
subject to the immunization requirements that indicates the
information specified in 2) a) above was received.

3) Requires the written statements signed by the health
care practitioner and the parent or guardian, as specified
in 2) a) and b) above to be signed not more than six months
from the date when the person subject to the immunization








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requirements is first admitted to the school. States that
if the person was admitted to the school prior to entering
the seventh grade and is about to enter the seventh grade,
then an additional letter or affidavit shall be filed with
the written statement signed by the parent or health care
practitioner not more than six months from the first day of
school.

4) Authorizes a copy of the signed written statement to be
accepted in lieu of the original form. Requires a signed
letter from the health care practitioner that references
the person's name to be accepted in lieu of a statement on
the original form.

5) Defines a health care practitioner for purposes of this
bill as any of the following:

a) A physician and surgeon licensed by the Medical Board of
California;
b) A nurse practitioner (NP) who is authorized to furnish
drugs, as authorized by law; or,
c) A physician assistant (PA) who is authorized to
administer or provide medication, as authorized by law.

EXISTING LAW :

1) Establishes the Division of Communicable Disease Control
(DCDC) within DPH to promptly identify, prevent, and
control infectious diseases that pose a threat to public
health, including emerging and re-emerging infectious
diseases, vaccine-preventable agents, bacterial toxins,
bioterrorism, and pandemics.

2)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, as specified:
Diphtheria; Haemophilus influenza type b,; measles; mumps;
pertussis; poliomyelitis; rubella; tetanus; hepatitis B;
varicella (chickenpox); and, any other disease deemed








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appropriate by DPH, taking into consideration the
recommendations of Advisory Committee on Immunization
Practices (ACIP), the American Academy of Pediatrics (AAP) and
the American Academy of Family Physicians.

3)Waives the requirement in 2) above for medical reasons 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 he or she
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 he or she 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 in 2) above and other
specified statutes, and requires counties to pay costs that
are not recovered from persons immunized.

FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.

COMMENTS :

1)PURPOSE OF THIS BILL . According to the author, "California is
one of only 20 states that allows for a personal beliefs, or
philosophical exemption to school or childcare immunization
requirements. Under existing law, to exempt the child from the
immunization requirements, a parent or guardian must only
provide a signed written statement or sign their name to a
two-sentence standard exemption statement on the back of the
School Immunization Record. While parents do have a choice to
exempt their children, they are not required to document their
concerns about vaccines or affirm that they have reviewed
fact-based, accurate information regarding the risks and
benefits of vaccines and the risks of vaccine-preventable
diseases. The continued increase in personal belief exemptions
and resultant decreases in community immunization rates in








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California will result in outbreaks of diseases such as measles,
mumps, and pertussis. Exposure to these preventable diseases
not only places the individual child at risk, but the entire
community, including infants too young to be fully immunized and
individuals with compromised immune systems, who are vulnerable
to complications of vaccine-preventable diseases, including
death. This measure would rectify this problem by creating a
process where parents would be able make an informed decision
for their children."

2)BACKGROUND .

a) Importance of Vaccination . According to the federal
Centers for Disease Control and Prevention (CDC), because
of advances in medical science, many children today are
protected against more diseases than ever before. Some
diseases that once injured or killed thousands of children
have been eliminated completely and others are close to
being gone because of safe and effective vaccines. For
example, polio was once a feared disease causing death and
paralysis but because of widespread vaccination, there are
no reports of polio in the United States (U.S.). CDC
points out that all vaccines are only given to children
after a long and careful review by scientists, doctors, and
healthcare professionals.

Federal law requires ACIP to provide advice and guidance to
the Secretary of the U.S. Department of Health and Human
Services (HHS), the Assistant Secretary for Health, and the
CDC on the most effective means to prevent
vaccine-preventable diseases. Another goal of ACIP is to
increase the safe usage of vaccines and related biological
products. ACIP consists of 15 experts in fields associated
with immunization who have been selected by the HHS
Secretary, and is the only entity in the federal government
which develops recommendations for the routine
administration of vaccines to children and adults, along
with schedules regarding the age for vaccine
administration, appropriate dosage, dosing intervals,
precautions, and contraindications applicable to the
vaccines.

b) Exemptions from School Immunization Requirements .








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School-aged children are required to obtain immunizations
for certain types of diseases to be admitted in school.
There are exceptions to this requirement. First, if the
physical or medical condition of a child would make
immunization unsafe, as long as a statement by a licensed
physician to this effect is submitted to the governing
authority. Second, if a letter or affidavit is filed with
the governing authority indicating that the immunization is
contrary to the beliefs of a parent or guardian; this
exemption is generally referred to as the personal belief
exemption (PBE) or philosophic exemption. According to the
CDC, aside from the philosophic exemption, some states
allow for religious exemptions on the ground that the
religious beliefs of some people are in opposition to
vaccination.

The National Conference of State Legislatures state that
forty-eight states allow religious exemptions (all but
Mississippi and West Virginia), and 20 states (California,
Colorado, Idaho, Louisiana, Maine, Michigan, Minnesota,
Missouri (limited to daycare, preschool and nursery
school), New Mexico, North Dakota, Ohio, Oklahoma,
Pennsylvania, Texas, Utah, Vermont, Washington, and
Wisconsin) permit philosophic exemptions. The criteria for
allowing these exemptions vary greatly by state. Some
states require membership in a recognized religion, whereas
other states, including California merely require an
affirmation of religious (or philosophic) opposition.

c) Legislative Briefing . On February 29, 2012 the author
hosted a legislative briefing entitled "Disease Prevention
through Immunization: A Community Responsibility." The
briefing included topics relating to vaccines and
preventable diseases, how immunization recommendations are
developed and how we know vaccines are safe, and the rapid
surge in PBEs.

During the legislative briefing, it was pointed out that the
number of parents or guardians choosing to exempt their
children from school immunization requirements has
increased. The graph below, provided by DPH, shows the
trend in PBE among kindergarten students from 1978-2010.









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DPH also presented a map of the percentage of PBEs in each
of California's counties. Populations in Del Norte,
Humboldt, Shasta, Mendocino, Sonoma, Marin, Santa Cruz,
Butte, Plumas, Nevada, El Dorado, and San Luis Obispo
Counties have a ratio of 5% to 17.7% of PBEs. Santa
Barbara, Ventura, Orange, and San Diego Counties range from
about 2.5% to 4.9% of PBEs; and, Merced, Glen, and Alpine
Counties have the least, each with less than 1% PBEs. DPH
indicated that the reasons for non-vaccination include
perception that children had low susceptibility to these
diseases; severity of the diseases was low; efficacy and
safety of the vaccines was low; and, the most frequent
reason (stated by 69% of the parents) was the concern the
vaccine might cause harm.

During the briefing, AAP, the California Immunization
Coalition, and the California Medical Association (CMA)
stated the following: based on 2010 research data from DPH,
the California Department of Education, and the U.S.
Census, California had about 11,500 kindergartners with
PBEs, representing a 25% increase over the previous two
years. The 2010 Kindergarten Assessment Report which
monitors compliance with the California School Immunization
Law, identifies the overall total of kindergarten entrants
with a PBE at 2.33%; with a range from 0% in Alpine County
to nearly 18% in Nevada County; and, over 30% of counties
had exemption rates more than 5%.

d) Examples of Outbreaks . During the Legislative briefing,
several outbreaks were discussed by DPH, including a 2008
San Diego measles outbreak where one intentionally
unvaccinated seven year old unknowingly infected with
measles returned from Switzerland, resulting in 839 people
exposed. The outbreak was fueled by clusters of additional
intentionally unvaccinated children and perpetuated by
delayed clinical diagnosis and inadequate infection-control
measures. The total outbreak costs in dollars alone were
$176,980.

The H1N1 outbreak is a more recent example. H1N1 is a new
strain of the influenza virus that first appeared in the
U.S. in April 2009 and spread worldwide. The symptoms of








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H1N1 are similar to the regular human seasonal flu
infection. According to DPH's Website, by December 2009,
more than 8,000 people in California were hospitalized, and
449 people died from H1N1. As a result of this outbreak,
legislation was passed which required school-aged children
to obtain pertussis immunization.

e) Other State Requirements . The sponsors cite the state
of Washington as an example of a state that changed the
requirements for obtaining PBE. On May 2011, legislation
was signed in Washington to require a licensed health care
provider to sign the Certificate of Exemption for a parent
or guardian to exempt their child from school and child
care immunization requirements. Similar to the
requirements in this bill, the signature of a health care
provider verifies that the parent or guardian was provided
information about the benefits and risks of immunization.

f) Studies Submitted by the Opposition . In stressing that
this bill would have a negative impact on families, the
opponents to this bill submitted two studies which they
claim prove the prevalence of physicians dismissing
families who delay and/or refuse vaccination. A 2011
article published in Public Health Reports titled,
"Physicians' Experience with and Response to Parental
Vaccine Safety Concerns and Vaccine Refusals: A Survey of
Connecticut Pediatricians" (2011 Article) examined how
frequently pediatricians in one New England state encounter
parental vaccine safety concerns and vaccine refusals.
According to the 2011 Article, the study consisted of a
quantitative survey of 133 pediatricians who completed the
questionnaire; the majority of responding pediatricians
reported an increase in parental vaccine safety concerns
and refusals. More than 30% indicated they have dismissed
families because of their refusal to immunize. Suburban
physicians caring for wealthier, better educated families
experience more vaccine concerns and/or refusals and are
more likely to dismiss families for vaccine refusal.
According to the 2011 Article, vaccine refusals have a
negative personal impact on one-third of physician
respondents. The 2011 Article also points out the AAP,
American Medical Association, and CDC all recommend against
discharging families solely based on vaccine refusal.








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In a 2005 study entitled "Dismissing the Family Who Refuses
Vaccines" published in the Archives of Pediatrics &
Adolescent Medicine (2005 Study), the objective was to
describe pediatrician's responses to scenarios of vaccine
refusal, identify reasons pediatricians cite for both
parent refusal and family dismissal and to illustrate
pediatrician attitudes about well-established versus newer
recommended vaccines. The 2005 Study conducted a
nationwide survey mailed to 1004 randomly selected members
of AAP members in Illinois. The findings of the 2005 study
are the following: 54% faced total vaccine refusal during a
12-month period; pediatricians cited safety concerns as a
top reason for parent refusal; 39% said they would dismiss
a family for refusing all vaccinations; and, 28% said they
would dismiss a family for refusing select vaccines. The
2005 study further pointed out that pediatrician dismissers
were not significantly different from nondismissers with
respect to age, sex, and number of years in practice.
Pediatrician dismissers were also more likely than
nondismissers to view traditional vaccines (diphtheria and
tetanus toxoids and acellular pertussis; inactivated
poliovirus; Haemophilus influenzae type b; measles, mumps,
and rubella) as "extremely important," but they were no
more likely to view newer vaccines (7-valent pneumococcal
conjugate, varicella-zoster virus, hepatitis B) as
"extremely important." The 2005 Study recognizes that the
practice of family dismissal needs further study to examine
its actual impact of vaccination rates, access to care, and
doctor-patient relations.

3)SUPPORT . The AAP, CMA, and the Health Officers Association of
California (HOAC) are the sponsors of this bill. They state
that this bill would increase protection for children and
communities from vaccine-preventable diseases, while still
respecting and preserving parent choice. They state that the
continued increase in PBEs and resultant decreases in
community immunization rates could have a significant impact
on public safety and because PBEs are relatively easy to
obtain, parents or schools may use them simply because they
find vaccination inconvenient, or because they have been
misinformed about the health effects of vaccines.









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The California Maternal, Child and Adolescent Health Directors,
the California School Health Centers Association, March of
Dimes, and the California Black Health Network also state in
support that this measure will make certain that all parents
are aware of the individual and public health risks of
exempting a child from required immunizations. They also
state that this bill increases the protection of children and
communities from vaccine-preventable diseases while still
respecting and preserving parent choice.

4)OPPOSITION . In opposition, the Pacific Justice Institute
states that existing law provides a reasonable process for
exemptions from mandated student vaccinations. This bill
changes the current approach and inserts more bureaucracy into
intimate medical decisions. The Health Advocacy in the Public
Interest indicates that parents must have the freedom to make
their own decisions with respect to the vaccination of their
children. Numerous letters from individuals, parents, and
practitioners state that this bill is an intrusion into the
personal freedom of parents to make health care decisions for
their children. They state that this measure causes undue
burden on parents, discriminates against families utilizing
complementary and alternative medicine; and promotes more
vaccine use and profit from the pharmaceutical industry.

5)OPPOSE UNLESS AMENDED . The California Naturopathic Doctors
Association (CNDA) has taken an oppose unless amended position
and requests that this measure be amended to include
naturopathic doctors (NDs) as one of the health care
practitioners that can provide a consultation to the parent or
guardian of a child subject to the requirements regarding the
benefits and risks of immunization. CNDA states that NDs are
licensed primary care providers in California who practice
integrative medicine, trained in both conventional and natural
approaches to medicine. NDs attend four-year post graduate
medical schools with federally-recognized accreditation and
are trained in the same medical sciences as MDs and doctors of
osteopathic medicine, and their medical education is greater
than NPs and PAs who are included in this bill as health care
providers authorized to provide the required letter.
Additionally, ND licensure includes the ability to prescribe
and administer vaccines. Washington state law, which is the
basis for this bill, also allows NDs to give the consultation








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and sign the required forms.

6)RELATED LEGISLATION . AB 2064 (V. Manuel Pérez), pending in
this Committee, requires a health care service plan or health
insurer that provides coverage for childhood and adolescent
immunizations to reimburse a physician or physician group in
an amount not less than the actual cost of acquiring the
vaccine plus the cost of administration of the vaccine, as
specified.

7)PREVIOUS LEGISLATION .

a) 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 for the 2011-12 school year, if that
pupil has not been fully immunized with all pertussis
boosters appropriate for the pupil's age if specified
conditions are met.

b) AB 354 (Arambula), Chapter 434, Statutes of 2010, allows
DPH to update vaccination requirements for children
entering schools and child care facilities and adds 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.

c) AB 1201 (V. Manuel Pérez) of 2009 would have required 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. AB 1201 was held on the Assembly
Appropriations Committee suspense file.

d) SB 1179 (Aanestad) of 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








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development center. SB 1179 died in Senate Health
Committee.

e) AB 2580 (Arambula) of 2008 would have required pupils
entering the seventh 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.

f) SB 676 (Ridley-Thomas) of 2007 would have required
pupils entering the seventh grade to be fully immunized
against pertussis. SB 676 was held on suspense in Assembly
Appropriations Committee.

g) SB 533 (Yee) of 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. SB 533 was vetoed by the Governor, who
stated that a mandate for this vaccination was not
necessary.

8)DEFINTION OF HEALTH PRACTITIONERS .

a) Osteopathic Physicians and Surgeons . Established by the
Osteopathic Initiative Act of 1922, osteopathic physicians
and surgeons practice medicine that emphasizes the
interrelationship between the structures and functions of
the body and recognizes the body's ability to heal itself.
Osteopathic physicians and surgeons have similar scope of
practice as physicians and surgeons in California. This
bill should be amended to include osteopathic physicians
and surgeons in the definition of health care
practitioners.

b) Naturopathic Doctors . Existing law under the
Naturopathic Doctors Act (Act) authorizes naturopathic
doctors to furnish or order drugs, including Schedule III
through Schedule V controlled substances under the
California Controlled Substances Act. The furnishing or
ordering of controlled substances by an ND must occur under








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physician and surgeon supervision. The Act further
provides that physician and surgeon supervision shall not
require physical presence of the physician but includes
collaboration on the development of standardized
procedures, approval of the standardized procedures or
availability by telephonic contact at the time of patient
examination by the ND. As such, it is within the scope of
an ND, under the supervision of physician, to administer
immunizations. A parent who is given advice on the risks
and benefits of vaccines and subsequently decides to
immunize his or her child could certainly obtain
immunization for the child not just from physicians and
surgeons but also NPs, and PAs and NDs who are under
physician and surgeon supervision. It should be noted that
the Washington statute that is the basis of this bill
includes NDs in the list of health care practitioners who
could provide immunization information and sign the
required written statement. In the same manner, should NDs
who are under physician and surgeon supervision be included
in the list of health practitioners who could provide
immunization information and sign the written statement
required by this bill?

REGISTERED SUPPORT / OPPOSITION :

Support

American Academy of Pediatrics (cosponsor)
California Medical Association (cosponsor)
Health Officers Association of California (cosponsor)
BayBio
California Black Health Network
California Hepatitis C Task Force
California Immunization Coalition
California Maternal, Child and Adolescent Health Directors
California Pharmacists Association
California School Health Centers Association
California State Association of Counties
Children's Healthcare is a Legal Duty, Inc.
Children's Hospital Los Angeles
Children's Specialty Care Coalition
Kaiser Permanente
March of Dimes California Chapter








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National Meningitis Association
Northeast Valley Health Corporation
San Francisco Department of Public Health
San Francisco Immunization Coalition
South Los Angeles Health Projects
Tracy Unified School District

Opposition

Association of American Physician and Surgeons (Tucson, AZ)
California Right to Life Committee
Canary Party
CHERISH Foundation
Child and Family Protection Association
CORE Sacramento
Exchange Club of Culver City
Families for Early Autism Treatment
Health Advocacy in the Public Interest
Maher Insurance and Financial Services
National Vaccine Information Center (Vienna, VA)
Pacific Justice Institute
Parental Rights.Org (Purcellville, VA)
Private School Advocacy Center (Purcellville, VA)
San Francisco Institute for Hyperbaric Medicine
Numerous individuals

Analysis Prepared by
: Rosielyn Pulmano / HEALTH / (916)
319-2097