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california legislation > AB 2109

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Date of Hearing: May 2, 2012

Felipe Fuentes, Chair

AB 2109 (Pan) - As Amended: April 23, 2012

Policy Committee:HealthVote:13-5

Urgency: No State Mandated Local Program:
Yes Reimbursable: Yes


This bill modifies the process for claiming Personal Beliefs
Exemption (PBE) to mandatory childcare and school immunization
requirements in California. Specifically, this bill:

1)Requires a parent or guardian of a child (or the person if an
emancipated minor) who wishes to file a PBE to mandatory
childcare or school immunization requirements to submit a form
prescribed by the California Department of Public Health or a
letter signed by a physician or other healthcare practitioner.

2)Requires the form or letter to state the health care
practitioner provided information about benefits and risks of
immunization, as well as information about the individual and
public health risks of communicable diseases for which
immunization is required.


1)Based on CDPH experience with another recent change to
immunization requirements, one-time costs for notification
including printing, mailing, and development of informational
materials in the range of $80,000 federal funds. Issuing
regulations and developing the form would result in one-time
staff time costs of $50,000, distributed among a number of
existing federally funded staff.

2)Minor, absorbable one-time costs to Department of Social
Services (DSS) Child Care Licensing Division staff and K-12
school administrative staff for training on the new

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3)Potential increase of $20,000 GF/98 annually in
state-reimbursable mandate costs to K-12 school administrative
staff to ensure compliance with the new form. DSS costs
related to ongoing enforcement are expected be minor and

4)Any impact on Medi-Cal or Healthy Families Program from a
small number of increased office visits, to the extent any
program enrollees seek exemptions and require additional
office visits to do so, is likely to be negligible.


1)Rationale . According to the author, this bill preserves a
parent's option to exempt their child from immunization
requirements and ensures that a decision to do so is an
informed one, based on accurate and up-to-date information
regarding individual and public health risks of not immunizing
their child. According to the author, the number of vaccine
exemptions has increased dramatically in the last decade,
leading to real concern about the loss of "herd immunity" and
potential for serious disease outbreaks, particularly in
school classrooms and communities whose exemption rates can
exceed 40%. He indicates that misinformation widely available
on the internet and sensationalist media reports have made it
more difficult for parents to receive accurate, fact-based
information about vaccines and to ascertain what information
is reliable. In addition, he indicates the bill will preserve
the right to exemption for those with deeply held beliefs,
while deterring parents who may request an exemption out of
convenience. Under current law, exemption only requires a
parent's signature and is simpler than submitting proof of

This bill is supported by a wide range of public health
agencies and medical associations, and is co-sponsored by the
California Medical Association, California Immunization
Coalition, American Academy of Pediatrics, and the Health
Officers Association of California.

2)Background . Vaccines are generally considered a crowning
public health achievement, and are credited with major
reductions in morbidity and mortality over the last century.
Vaccination is endorsed by major national and international

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public health entities including the Centers for Disease
Control and Prevention (CDC) and World Health Organization, as
well as major medical associations. Public health entities
promoting disease prevention through vaccination state that
vaccination programs have in some ways been a "victim of their
own success"; it has been documented that as the incidence of
disease decreases due to high vaccination rates, public
attention shifts away from the risks of disease and to the
risk of vaccination.

3)Vaccination Risks and Benefits . No vaccine is 100% effective
in every person, or 100% risk-free. On balance, the benefits
of vaccination on a population basis greatly exceed the risks.
The Centers for Disease Control and Prevention (CDC) indicates
serious reactions to vaccines are possible, but are extremely
rare on a population basis. For example, CDC states the
chance of encephalitis or severe allergic reaction as a result
of the measles-mumps-rubella (MMR) vaccine is 1 in 1,000,000.
In contrast, the risk of death if someone contracts measles is
about 1 in 500 and the risk of pneumonia exceeds 1 in 20.
Given that measles and other diseases are no longer endemic to
California due to widespread vaccination, one unvaccinated
child may still have a low risk of contracting measles in
California today because he or she is protected by the "herd
immunity" of the surrounding community or school. If that
immunity wanes due to a reduction in vaccination rates,
however, many of the diseases for which vaccination is
recommended would reemerge quickly.

Despite scientific evidence and consensus to the contrary,
information exaggerating the risks and minimizing the benefits
of vaccination is widespread. Over the last decade, based on
a faulty U.K. study that has been formally retracted and
disavowed by most of its authors, concern that the
measles-mumps-rubella (MMR) vaccine causes autism has remained
an object of media attention and controversy.

4)School Vaccination Requirements
. For vaccination to
dramatically reduce or eliminate disease transmission,
vaccination rates must be very high; for example, preventing
transmission of measles requires vaccination rates of up to
95%. Mandatory vaccination for school entry has been an
important tool to encourage population coverage rates at
levels adequate to prevent disease transmission.

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Exemptions from mandatory vaccination for medical reasons are
allowed in every state, and all states but two allow a
religious exemption. California is one of 20 states that
allows a broader personal belief exemption. Many states with
personal belief or religious exemptions require something
beyond a signature; for example, New Mexico requires parents
seeking an exemption to submit a notarized certificate of
conscientious objection. The exemption request may be
disapproved by public health officials if the certificate's
stated beliefs and practices are judged insufficient to
warrant an exemption. Not all recommended vaccinations are
required for school entry; for example, the human papilloma
virus (HPV) vaccine to prevent cervical cancer, which has also
generated controversy in recent years, is not required.

Currently, about 2.5% of California children are exempt
through a PBE, but this number has been growing rapidly since
2001. Exempted children are not evenly geographically
distributed throughout the state. Persons requesting PBE tend
to cluster in certain areas, and are more likely to be white,
speak English primarily, and have higher socioeconomic status.

5)Opposition . A large number of individuals, as well as several
anti-vaccine and vaccine safety advocacy groups oppose this
bill. Many individuals state that they currently rely on
holistic or alternative healing methods, contend that this
bill will force them into a unwanted relationship with a
medical provider, and express concern about the costs of a
visit to a medical provider. In addition, a variety of
individuals opposed to this measure cite a variety of other
reasons, including beliefs that the bill is an infringement of
their constitutional rights to make medical decisions for
their children, that the bill is a ploy by pharmaceutical
companies to boost vaccine sales, that children who are not
vaccinated pose no risk to vaccinated children, that parents
who refuse exemption know more than their pediatricians about
vaccine safety, and that improved sanitation, not vaccination,
is responsible for large reductions in communicable disease.

Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081