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california legislation > AB 2109

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SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair

BILL NO: AB 2109
AUTHOR: Pan
AMENDED: June 20, 2012
HEARING DATE: June 27, 2012
CONSULTANT: Moreno

SUBJECT : Communicable disease: immunization exemption.

SUMMARY
: Requires, after July 1, 2014, a separate form
prescribed by the Department of Public Health (DPH) to accompany
a letter or affidavit to exempt a child from immunization
requirements under existing law on the basis that immunization
is contrary to beliefs of the child's parent or guardian.

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), measles, mumps, pertussis, poliomyelitis, rubella,
tetanus, hepatitis b (except after 7th grade), and chickenpox,
as specified.

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 (AAP) Committee on Infectious Diseases.


3.Waives the above requirements if the parent or guardian or
adult who has assumed responsibility for the child's care and
custody, or the person seeking admission, if an emancipated
minor, files a letter or affidavit with the governing
authority stating that the immunization is contrary to his or
her beliefs.

4.Permits 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, to
Continued---



AB 2109 | Page 2




be temporarily excluded from the school or institution until
the local health officer is satisfied that the child is no
longer at risk of developing the disease.

This bill:
1.Requires, after July 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
immunization is contrary to the beliefs of the child's parent
or guardian.

2.Requires the form to include:
a. A signed attestation from a health care practitioner
that indicates that he or she provided the parent or
guardian of the person who is subject to the immunization
requirements in existing law, the adult who has assumed
responsibility for the care and custody of the person, or
to the person if he or she is a emancipated minor, with
information regarding the benefits and risks of the
immunization and the health risks of specified communicable
diseases to the person and to the community.
b. A written statement signed by the parent or guardian of
the person who is subject to the immunization requirements
in existing law, the adult who has assumed responsibility
for the care and custody of the person, or the person if he
or she is an emancipated minor, that indicates that the
signer has received the information provided by the health
care practitioner.

3.Requires the form to be signed not more than 6 months prior to
the date when the person first becomes subject to the
immunization requirement for which exemption is being sought.

4.Permits a photocopy of the signed form or a letter signed by a
health care practitioner that includes all information and
attestations included on the form to be accepted in lieu of
the original form.

5.Defines, for the purposes of this bill, a "health care
practitioner" as a physician and surgeon, a nurse
practitioner, a physician assistant, an osteopathic physician
and surgeon, or a naturopathic doctor, as specified.

6.Exempts issuance and revision of the form from rulemaking
requirements under the Administrative Procedure Act.





AB 2109 | Page
3




FISCAL EFFECT : According to the Assembly Appropriations
Committee, based on DPH 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.

a.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
requirement.
b.Potential increase of $20,000 General Fund/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
absorbable.
c.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.

PRIOR VOTES :
Assembly Health: 13- 5
Assembly Appropriations:12- 5
Assembly Floor: 47- 26

COMMENTS
:
1.Author's statement. California is 1 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 California will
result in outbreaks of diseases such as measles, mumps, and
pertussis. Exposure to these preventable diseases not only




AB 2109 | Page 4




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. his measure would rectify this problem by
creating a process where parents would be able make an
informed decision for their children.

2.Immunizations. According to the CDC, vaccines contain the
same antigens or parts of antigens that cause diseases, but
the antigens in vaccines are either killed or greatly
weakened. Vaccine antigens are not strong enough to cause
disease but, they are strong enough to make the immune system
produce antibodies against them. Memory cells prevent
re-infection when they encounter that disease again in the
future. Vaccines are responsible for the control of many
infectious diseases that were once common around the world,
including polio, measles, diphtheria, pertussis (whooping
cough), rubella (German measles), mumps, tetanus, and Hib.
Vaccine eradicated 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. According to DPH,
implementation of statewide immunization requirements has been
effective in maintaining a 92 percent immunization coverage
rate among children in licensed child care facilities and
kindergartens.

3.ACIP. ACIP consists of 16 experts in fields associated with
immunization who have been selected by the Secretary of the
U.S. Department of Health and Human Services to provide advice
and guidance to the Secretary, the Assistant Secretary for
Health, and the CDC on the most effective means to prevent
vaccine-preventable diseases. ACIP develops written
recommendations for the routine administration of vaccines to
pediatric and adult populations, along with schedules
regarding the appropriate periodicity, dosage, and
contraindications applicable to the vaccines and is the only
entity within the federal government which makes such
recommendations. The overall goals of ACIP are to provide
advice to assist in reducing the incidence of




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5




vaccine-preventable diseases and to increase the safe usage of
vaccines and related biological products.

ACIP, along with AAP and the American Academy of Family
Physicians, approved the 2012 Recommended Immunization
Schedules for Persons Aged 0 Through 18 Years. Children under
six are recommended to receive vaccines for: hepatitis b;
rotavirus; diphtheria, tetanus, and pertussis (DTaP); Hib;
pneumococcal; polio; influenza; measles, mumps, rubella (MMR);
varicella; hepatitis a; and meningococcal.

4.School vaccination 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 2001-2002
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 United States 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.





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5.Exemptions to vaccine requirements. There are two types of
non-medical exemptions to the requirement that children be
vaccinated before entering school: religious exemption and
philosophical exemption. Religious exemption means that there
is a provision in the statute that allows parents to exempt
their children from vaccination if it contradicts their
sincere religious beliefs. Philosophical exemption 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 the National
Conference of State Legislatures, as of February 2012, 48
states allow religious exemptions (all but Mississippi and
West Virginia), and 20 states (Arizona, 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, West Virginia 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,
merely require an affirmation of religious (or philosophic)
opposition.

6.Author's briefing. On February 29, 2012, the author hosted a
briefing, "Disease Prevention through Immunization: A
Community Responsibility," which included topics relating to
vaccines and preventable diseases, how immunization
recommendations are developed and vaccine safety, and the
increase in personal belief exemptions (PBEs). During the
briefing, it was pointed out that the number of parents or
guardians choosing to exempt their children from school
immunization requirements has increased. DPH demonstrated the
trend in PBE among kindergarten students over a 32-year span,
which has gone from below .5 percent in 1978 to almost 2.5
percent in 2010.

DPH also presented a map of the percentage of PBEs in each of
California's counties, which range significantly. In Del
Norte, Humboldt, Shasta, Mendocino, Sonoma, Marin, Santa Cruz,
Butte, Plumas, Nevada, El Dorado, and San Luis Obispo
counties, between 5 percent and 17.7 percent of children are
entering kindergarten with PBEs. Santa Barbara, Ventura,
Orange, and San Diego Counties have between 2.5 percent and
4.9 percent of children entering kindergarten with PBEs.




AB 2109 | Page
7




Merced, Glen, Alpine, and Imperial counties have the least
percentage of kindergarteners with PBEs, with less than one
percent. DPH indicated that the reasons for non-vaccination
nationwide 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 percent of the parents) was the
concern the vaccine might cause harm.

7.Physician dismissing of patients. In stressing that this bill
would have a negative impact on families, the opponents to
this bill submitted two studies to demonstrate 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 a
questionnaire; the majority of responding pediatricians
reported an increase in parental vaccine safety concerns and
refusals. More than 30 percent 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.

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 1,004
randomly selected members of AAP in Illinois. The study found:
54 percent faced total vaccine refusal during a 12-month
period; pediatricians cited safety concerns as a top reason




AB 2109 | Page 8




for parent refusal; 39 percent said they would dismiss a
family for refusing all vaccinations; and 28 percent said they
would dismiss a family for refusing select vaccines.

8.Related legislation. AB 2064 (V. Manuel Pérez) 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 in an amount not
less than the actual cost of acquiring the vaccine plus the
cost of administration of the vaccine, as specified. AB 2064
was held on suspense in the Assembly Appropriations Committee.

9.Prior legislation. SB 614 (Kehoe), Chapter 123, Statutes of
2011, allowed 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.

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 7
through 12 receive a TDaP booster prior to admittance to
school.

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.

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 development center. SB 1179
died in Senate Health Committee.

AB 2580 (Arambula) of 2008 would have required pupils entering




AB 2109 | Page
9




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.

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.

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.

10.Support. The AAP, California Medical Association, and the
Health Officers Association of California (HOAC), joint
sponsors of this bill, 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.

The California Maternal, Child and Adolescent Health Directors,
the California School Health Centers Association, March of
Dimes, and the California Black Health Network state that this
bill 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.

11.Opposition. The Pacific Justice Institute states that
existing law provides a reasonable process for exemptions from
mandated student vaccinations. This bill changes the current




AB 2109 | Page 10




approach and inserts more bureaucracy into intimate medical
decisions. 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 an undue burden on parents,
discriminates against families utilizing complementary and
alternative medicine, and promotes more vaccine use and profit
from the pharmaceutical industry.

SUPPORT AND OPPOSITION :
Support: American Academy of Pediatrics (co-sponsor)
California Medical Association (co-sponsor)
Health Officers Association of California (co-sponsor)
Association of Northern California Oncologists
BayBio
California Black Health Network
California Hepatitis C Task Force
California Immunization Coalition
California Naturopathic Doctors Association
California Pharmacists Association
California Primary Care Association
California School Health Centers Association
California State Association of Counties
County Health Executives Association of California
Los Angeles County Board of Supervisors
Los Angeles Unified School District
March of Dimes California Chapter
San Francisco Immunization Coalition
Santa Clara County Board of Supervisors
Tracy Unified school District
Two individuals

Oppose: California Federation of Republican Women
California Right to Life Committee, Inc.
Canary Party
Child and Family Protection Association
CORE Sacramento
Health Advocacy in the Public Interest
Maher Insurance and Financial Services
National Vaccine Information Center
Pacific Justice Institute
ParentalRights.Org
Private School Advocacy Center




AB 2109 | Page
11




Over 400 individuals

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