Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home. Existing law requires an applicant for licensure as a family day care home to present evidence of a current tuberculosis clearance for any adult in the home during the time that children are under care.

This bill, commencing September 1, 2016, would prohibit a person from being employed or volunteering at a day care center or a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would require a day care center or a family day care home to maintain documentation of the required immunizations or exemptions from immunization in the employees or volunteers personnel record. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care home. The bill would provide that a violation of these provisions would not be subject to a crime. The bill would require any person hired as a teacher in a day care center to present evidence of a current tuberculosis clearance, as specified.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home. Existing law requires an applicant for licensure as a family day care home to present evidence of a current tuberculosis clearance for any adult in the home during the time that children are under care.

This bill, commencing September 1, 2016, would prohibit a person from being employed or volunteering at a day care center or a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would require a day care center or a family day care home to maintain documentation of the required immunizations or exemptions from immunization in the employees or volunteers personnel record. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care home. The bill would provide that a violation of these provisions would not be subject to a crime. The bill would require any person hired as a teacher in a day care center to present evidence of a current tuberculosis clearance, as specified.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home. Existing law requires an applicant for licensure as a family day care home to present evidence of a current tuberculosis clearance for any adult in the home during the time that children are under care.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any a person who from being employed or volunteering at a day care center or a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would require a day care center or a family day care home to maintain documentation of the required immunizations or exemptions from immunization in the employees or volunteers personnel record. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care home. The bill would provide that a violation of these provisions would not be subject to a crime. The bill would require any person hired as a teacher in a day care center to present evidence of a current tuberculosis clearance, as specified.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home. Existing law requires an applicant for licensure as a family day care home to present evidence of a current tuberculosis clearance for any adult in the home during the time that children are under care.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any person who has not been immunized against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care home. The bill would provide that a violation of these provisions would not be subject to a crime. The bill would require any person hired as a teacher in a day care center to present evidence of a current tuberculosis clearance, as specified.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any person who has not been immunized against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care home. Because the bill would extend the application of a crime under the act, the bill would impose a state-mandated local program. The bill would provide that a violation of these provisions would not be subject to a crime.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any person who has not been immunized against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care home. Because the bill would extend the application of a crime under the act, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any person who has not been immunized in accordance with the schedule for routine adult immunizations, prescribed by the federal Centers for Disease Control and Prevention. against influenza, pertussis, and measles. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety, current immunity, or declining the influenza vaccination, or the date upon which he or she was hired, as specified. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care center home. Because the bill would extend the application of a crime under the act, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any person who has not been immunized in accordance with the schedule for routine adult immunizations, prescribed by the federal Centers for Disease Control and Prevention. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety and safety, current immunity, or declining the influenza vaccination, as specified. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care center. Because the bill would extend the application of a crime under the act, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home.

This bill, commencing September 1, 2016, would prohibit a day care center or a family day care home from employing any person who has not been immunized against influenza, pertussis, and measles. in accordance with the schedule for routine adult immunizations, prescribed by the federal Centers for Disease Control and Prevention. The bill would specify circumstances under which a person would be exempt from the immunization requirement, based on medical safety and current immunity, as specified. The bill would make conforming changes to provisions that set forth qualifications for day care center teachers and applicants for licensure as a family day care center. Because the bill would extend the application of a crime under the act, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the California Child Day Care Facilities Act, provides for the licensure and regulation of day care centers, as defined, and family day care homes, as defined, by the State Department of Social Services. A violation of the act is a crime. Existing law requires a child to be immunized prior to admission to a day care center or family day care home. Existing law authorizes an exemption from those provisions for medical reasons or because of personal beliefs, if specified forms are submitted to the day care center or family day care home.

This bill would prohibit a day care center or a family day care home from employing any person who has not been immunized against influenza, pertussis, and measles. Because the bill would extend the application of a crime under the act, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

 UNFINISHED BUSINESS  

Bill No: SB 792

Author: Mendoza (D)

Amended: 9/4/15

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 4/15/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Pan, Roth, Wolk

NO VOTE RECORDED: Nielsen

SENATE HUMAN SERVICES COMMITTEE: 3-0, 4/28/15

AYES: McGuire, Berryhill, Hancock

NO VOTE RECORDED: Liu, Nguyen

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SENATE FLOOR: 34-3, 5/22/15

AYES: Allen, Bates, Beall, Berryhill, Block, Cannella, De León, Gaines, Galgiani, Hall, Hancock, Hernandez, Hertzberg, Hill, Hueso, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Nguyen, Nielsen, Pan, Pavley, Roth, Runner, Stone, Vidak, Wieckowski, Wolk

NOES: Anderson, Moorlach, Morrell

NO VOTE RECORDED: Fuller, Huff

ASSEMBLY FLOOR: 60-16, 9/08/15 - See last page for vote

SUBJECT: Day care facilities: immunizations: exemptions

SOURCE: Health Officers Association of California

DIGEST: This bill prohibits, commencing September 1, 2016, a person from being employed or volunteering at a day care center or a day care home if he or she has not been immunized against influenza, pertussis, and measles.

Assembly Amendments add volunteers to those individuals that are required to be immunized; narrow the required vaccines to influenza, pertussis, and measles; add a 30-day grace period for required immunizations; require day care centers to maintain documentation of the required immunizations or exemptions, as specified; specify that a violation of this bill would not be subject to a crime; and, make other technical, clarifying changes.

ANALYSIS:

Existing law:

1. Permits a person to be hired as a teacher in a day care center if he or she is 18 years or older and meets certain educational requirements.

2. Requires family day care homes for children to apply to the Department of Social Services (DSS) for a license and requires applicants to file an application on forms furnished by DSS, as specified, and to include specified documentation related to finances, fire safety, employee fingerprints, and tuberculosis clearance.

3. Prohibits the governing authority of a school or other institution from unconditionally admitting any person as a pupil of private or public elementary or secondary schools, child care centers, day nurseries, nursery schools, family day care homes, or development centers, unless, prior to 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.

4. Permits the Department of Public Health (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.

5. Waives the above immunization requirements 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 or medical circumstances relating to the child are such that immunization is not considered safe. Requires the statement to indicate the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization.

6. Waives the above immunization 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 with the governing authority stating that the immunization is contrary to his or her beliefs (commonly referred to as a “personal belief exemption” or “PBE.”)

7. Requires a separate form prescribed by DPH to accompany a PBE. Requires the form to include:

   1. A signed attestation from a 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. Requires the attestation to be signed within six months of the date when the person first becomes subject to the immunization requirement for which the PBE is being sought.

   2. 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 received the information provided by the health care practitioner pursuant to a) above. Requires the statement to be signed within six months of the date when the person first becomes subject to the immunization requirements.

8. 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 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. Prohibits, commencing September 1, 2016, a person from being employed or being a volunteer at a day care center or a day care home if he or she has not been immunized against influenza, pertussis, and measles. Requires an employee or volunteer to receive an influenza vaccination between August 1 and December 1 of each year.

2. Permits a person, if he or she meets all other requirements for employment or volunteering, as applicable, but needs additional time to obtain and provide his or her immunization records, to be employed or volunteer conditionally for a maximum of 30 days upon signing and submitting a written statement attesting that he or she has been immunized as required.

3. Exempts a person from this requirement if the person:

1. Submits a written statement from a licensed physician declaring that because of the person’s physical condition or medical circumstances, immunization is not safe;

2. Submits a written statement from a licensed physician providing that the person has evidence of current immunity to influenza, pertussis, and measles; or

3. Submits a written declaration that he or she has declined the influenza vaccination.

4. Was hired after December 1 of the previous year and before August 1 of the current year. Specifies that this exemption applies only to the influenza vaccine during the first year of employment or volunteering.

4. Requires the day care center to maintain documentation of the required immunizations or exemptions from immunization, in the person’s personnel record that is maintained by the day care center.

5. Places the immunization requirement above on day care teachers. Requires any person hired as a day care teacher to present evidence of a current tuberculosis clearance.

6. Requires, as a condition of licensing by DSS commencing September 1, 2016, family day care home applicants to provide evidence of current immunity pursuant to 1) above for the applicant and any other person who provides care and supervision to the children.

7. Specifies that a violation of this bill would not be subject to a crime.

Comments:

1. Author’s statement. According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease (community immunity). This bill will protect children in day care by requiring those who care for them to maintain immunity. Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and perhaps even be fatal in an infant or an individual with a suppressed immune system. Other diseases in the ACIP schedule include very serious conditions, formerly under control, that have resurfaced in recent years, including pertussis and measles. By requiring vaccination for pre-school workers, vulnerable children will be “cocooned” from potentially serious illness, and day care centers will be a safe and healthy place for our little ones to learn and play.

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. Vaccines 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.

3. ACIP. The ACIP consists of 15 experts who are voting members and are responsible for making vaccine recommendations. The Secretary of the U.S. Department of Health and Human Services selects these members after an application, interview, and nomination process. Fourteen of the members have expertise in vaccinology, immunology, pediatrics, internal medicine, nursing, family medicine, virology, public health, infectious diseases, and/or preventive medicine; one member is a consumer representative who provides perspectives on the social and community aspects of vaccination. 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 vaccine-preventable diseases and to increase the safe usage of vaccines and related biological products.

ACIP, along with AAP, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, approved the 2015 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. California Vaccination Rates. According to an August 2014 DPH fact sheet, vaccination coverage in California is at or near all-time high levels. DPH states that the implementation of current vaccine requirements has been effective in maintaining greater than or equal to 92 % immunization coverage among children in licensed child care facilities and kindergartens. DPH would like immunization rates to be as close to 100 % as possible, and is using national Healthy People 2020 objectives as a benchmark to monitor progress. These objectives include: toddlers/pre-school: 90 % rate for four doses of DTaP, 3 or 4 doses of Hib vaccine, 3 doses of hepatitis b vaccine, 1 dose of MMR, 3 doses of polio vaccine, and one dose of varicella vaccine; kindergarteners: 95 % rate for 4 doses DTaP, 2 MMR, 3 polio vaccine, 3 hepatitis b vaccine, and 2 doses of varicella vaccine; and for 13 to 15 year olds: 80 % Tdap vaccination rate. The DPH Immunization Branch maintains data on its website related to vaccination rates and is searchable statewide and by school (kindergarten and seventh grade rates) and child care facility. This year, 89.4 % of the 434,922 children aged two to five years enrolled in reporting child care facilities received all required immunizations (4+ DTP, 3+ Polio, 1+ MMR, 1+ Hib, 3+ Hep B, and 1+ Vari or physician-documented varicella disease), a 0.1 % increase from the prior year. ‘Conditional’ entrants (children in process to be fully vaccinated but not yet having all required vaccinations), decreased by 0.1 % this past year. There were 2,734 (0.56 %) children with permanent medical exemptions (PMEs) and 12,981 (2.67 %) with PBEs. Children with PBEs decreased from 2.94 % this past year. For all facilities, immunization coverage was greater than or equal to 94 % for each vaccine this year.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

According to Assembly Appropriations Committee, costs to the Department of Social Services (DSS), which licenses child care facilities, are expected to be minor and absorbable.

SUPPORT: (Verified 9/8/15)

Health Officers Association of California (source)

Alameda County Board of Supervisors

American Academy of Pediatrics, California

American Nurses Association\California

California Academy of Family Physicians

California Academy of Preventative Medicine

California Federation of Teachers

California Hospital Association

California Immunization Coalition

California Medical Association

California Primary Care Association

California Public Health Association-North

Child Care Law Center

Children Now

County Health Executives Association of California

First 5 California

Knowledge Universe

Los Angeles County Board of Supervisors

March of Dimes, California Chapter

National Association of Social Workers, California Chapter

Santa Clara County Board of Supervisors

OPPOSITION: (Verified 9/8/15)

Educate Operate 

California Coalition for Health Choice

Your Family Your Choice

ASSEMBLY FLOOR: 60-16, 9/08/15

AYES: Alejo, Travis Allen, Baker, Bloom, Bonilla, Bonta, Brown, Burke, Calderon, Campos, Chang, Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Daly, Dodd, Eggman, Frazier, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Hadley, Roger Hernández, Holden, Irwin, Jones-Sawyer, Kim, Lackey, Levine, Lopez, Low, Maienschein, McCarty, Medina, Mullin, Nazarian, O'Donnell, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Weber, Wood, Atkins

NOES: Achadjian, Brough, Dahle, Beth Gaines, Gallagher, Grove, Harper, Jones, Linder, Mathis, Mayes, Melendez, Obernolte, Patterson, Waldron, Wilk

NO VOTE RECORDED: Bigelow, Chávez, Olsen, Williams

Prepared by: Melanie Moreno / HEALTH /

9/8/15 19:34:35

**** END ****

SENATE THIRD READING

STR Bill Id:SB 792

Author:(Mendoza)

As Amended Ver:September 4, 2015

Majority vote

SENATE VOTE: 34-3

SUMMARY: Requires day care workers or volunteers to be vaccinated for specified infectious diseases as a condition of participation. Specifically, this bill:

1. Prohibits, after September 1, 2016, a day care center or a family day care home from employing any person, or allowing any person to volunteer, who has not been immunized against measles, pertussis, and influenza (flu).

2. Specifies circumstances under which a person would be exempt from the immunization requirement based on medical safety, current immunity, or, for flu vaccine, timing of hire or employee declination.

3. Permits a person to be employed or volunteer conditionally for 30 days after submitting a written statement attesting that they have been immunized as required, but need additional time to obtain and provide their records.

4. Requires any person hired or volunteering as a teacher in a day care center to present evidence of a current tuberculosis clearance, as specified.

FISCAL EFFECT: According to the Assembly Appropriations Committee, costs to Department of Social Services, which licenses child care facilities, are expected to be minor and absorbable.

COMMENTS: According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease. The author states that this bill will protect children in day care by requiring those who care for them to maintain immunity.

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. Vaccines 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.

Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and be potentially fatal for infants or individuals with suppressed immune systems. Importantly, many vaccines require multiple doses before a child is protected against the disease, and children in day care settings are often too young to complete the recommended series of vaccinations.

1. Pertussis is a highly contagious bacterial disease that can be spread by coughing. People with pertussis have severe coughing attacks that can last for months. Infants too young for vaccination are at greatest risk for life-threatening cases of pertussis. Pertussis vaccinations are given starting at two months of age, but multiple doses are required before the child is considered fully immunized. According to the California Department of Public Health, during a major pertussis outbreak in 2010, there were 9,000 cases of pertussis resulting in 10 infant deaths. In 2014, there were 11,114 reported cases of whooping cough with three infant deaths. As of June 1, 2015 there have been 2,552 new cases of pertussis in California this year. Sixty-two infants younger than four months of age have been hospitalized and one death was reported in an infant that contracted pertussis at three weeks of age.

2. Measles is a highly contagious viral disease, and is considered the most deadly of all childhood rash/fever illnesses. It is recommended that children receive their first measles vaccination at 12 to 15 months; to be most effective, a second dose is recommended at four to six years. Measles is particularly dangerous for babies and young children. From 2001-13, 28% of children younger than five years old who had measles had to be treated in the hospital. For some children, measles can lead to pneumonia, lifelong brain damage, deafness, or death. According to the Centers for Disease Control and Prevention (CDC), the United States declared that measles was eliminated from this country in 2000; however, 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 December 2014 outbreak in California, which is one of five outbreaks so far this year reported by the CDC.

3. Influenza, or flu, is a contagious respiratory illness caused by influenza viruses. The CDC recommends a yearly flu vaccine for everyone six months of age and older as the first and most important step in protecting against this serious disease. Because there are many different flu viruses, the flu vaccine is redesigned annually to protect against the flu strains that research indicates will cause the most illness during the flu season. Last year in California, 10 children died of influenza. According to the CDC's nationwide surveillance, 142 children passed away during the 2014-15 flu season due to complications with the flu, bringing the total of pediatric deaths since 2004 to over 1,000.

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 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.

In recent years a few other states, including Vermont, Colorado, and Illinois have considered legislation to require vaccinations for teachers or child care workers. In 2014, Texas passed a law requiring child-care facilities to develop and implement a policy concerning vaccination of employees.

The Health Officers Association of California, sponsor of this bill, writes that given that child care workers have close, intimate contact with children who are unable to be fully immunized, it is important to ensure that these dedicated professionals are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases. Knowledge Universe, the Santa Clara County Board of Supervisors and other supporters state that it is important to ensure that child care professionals are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases.

The California Right to Life Committee and several other groups opposed to vaccination mandates state that this bill places an unwarranted burden on child care employees, as well as an unnecessary mandate that day care owners must enforce.

Analysis Prepared by: Dharia McGrew / HEALTH / (916) 319-2097 FN: 0002104

SENATE THIRD READING

STR Bill Id:SB 792

Author:(Mendoza)

As Amended Ver:August 19, 2015

Majority vote

SENATE VOTE: 34-3

SUMMARY: Requires day care workers to be vaccinated for specified infectious diseases as a condition of employment. Specifically, this bill:

1. Prohibits, after September 1, 2016, a day care center or a family day care home from employing any person who has not been immunized against measles, pertussis, and influenza (flu).

2. Specifies circumstances under which a person would be exempt from the immunization requirement based on medical safety, current immunity, or, for flu vaccine, timing of hire or employee declination.

3. Narrows current broad-based tuberculosis testing requirements for day care workers by conforming to a risk-based methodology that currently applies to teachers.

FISCAL EFFECT: According to the Assembly Appropriations Committee, costs to DSS, which licenses child care facilities, are expected to be minor and absorbable.

COMMENTS: According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease. The author states that this bill will protect children in day care by requiring those who care for them to maintain immunity.

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. Vaccines 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.

Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and be potentially fatal for infants or individuals with suppressed immune systems. Importantly, many vaccines require multiple doses before a child is protected against the disease, and children in day care settings are often too young to complete the recommended series of vaccinations.

1. Pertussis is a highly contagious bacterial disease that can be spread by coughing. People with pertussis have severe coughing attacks that can last for months. Infants too young for vaccination are at greatest risk for life-threatening cases of pertussis. Pertussis vaccinations are given starting at two months of age, but multiple doses are required before the child is considered fully immunized. According to DPH, during a major pertussis outbreak in 2010, there were 9,000 cases of pertussis resulting in 10 infant deaths. In 2014, there were 11,114 reported cases of whooping cough with three infant deaths. As of June 1, 2015 there have been 2,552 new cases of pertussis in California this year. Sixty-two infants younger than four months of age have been hospitalized and one death was reported in an infant that contracted pertussis at three weeks of age.

2. Measles is a highly contagious viral disease, and is considered the most deadly of all childhood rash/fever illnesses. It is recommended that children receive their first measles vaccination at 12 to 15 months; to be most effective, a second dose is recommended at four to six years. Measles is particularly dangerous for babies and young children. From 2001-13, 28% of children younger than five years old who had measles had to be treated in the hospital. For some children, measles can lead to pneumonia, lifelong brain damage, deafness, or death. According to the Centers for Disease Control and Prevention (CDC), the United States declared that measles was eliminated from this country in 2000; however, 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 December 2014 outbreak in California, which is one of five outbreaks so far this year reported by the CDC.

3. Influenza, or flu, is a contagious respiratory illness caused by influenza viruses. The CDC recommends a yearly flu vaccine for everyone six months of age and older as the first and most important step in protecting against this serious disease. Because there are many different flu viruses, the flu vaccine is redesigned annually to protect against the flu strains that research indicates will cause the most illness during the flu season. Last year in California, 10 children died of influenza. According to the CDC's nationwide surveillance, 142 children passed away during the 2014-15 flu season due to complications with the flu, bringing the total of pediatric deaths since 2004 to over 1,000.

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 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.

In recent years a few other states, including Vermont, Colorado, and Illinois have considered legislation to require vaccinations for teachers or child care workers. In 2014, Texas passed a law requiring child-care facilities to develop and implement a policy concerning vaccination of employees.

The Health Officers Association of California, sponsor of this bill, writes that given that child care workers have close, intimate contact with children who are unable to be fully immunized, it is important to ensure that these dedicated professionals are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases. Knowledge Universe, the Santa Clara County Board of Supervisors and other supporters state that it is important to ensure that child care professionals are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases.

The California Right to Life Committee and several other groups opposed to vaccination mandates state that this bill places an unwarranted burden on child care employees, as well as an unnecessary mandate that day care owners must enforce.

Analysis Prepared by: Dharia McGrew / HEALTH / (916) 319-2097 FN: 0001796

Date of Hearing: August 26, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

SBPCA Bill Id:SB 792

Author:(Mendoza) – As Amended Ver:August 19, 2015

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

SUMMARY:

This bill requires day care workers to be vaccinated for specified infectious diseases as a condition of employment. Specifically, this bill:

1. Prohibits, after September 1, 2016, a day care center or a family day care home from employing any person who has not been immunized against measles, pertussis, and influenza (flu).

2. Specifies circumstances under which a person would be exempt from the immunization requirement based on medical safety, current immunity, or, for flu vaccine, timing of hire or employee declination.

3. Narrows current broad-based tuberculosis testing requirements for day care workers by conforming to a risk-based methodology that currently applies to teachers.

FISCAL EFFECT:

Costs to the Department of Social Services (DSS), which licenses child care facilities, are expected to be minor and absorbable.

COMMENTS:

1. Purpose. According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease (community immunity). This bill will protect children in day care by requiring those who care for them to maintain immunity.

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. Some diseases that are non-serious in adults can be dangerous, and perhaps even fatal, for an infant or an individual with a suppressed immune system. Last year, in California, ten children died of influenza. During the last major pertussis outbreak in 2010, there were 9,000 cases of whooping cough and ten infant deaths. This bill is intended to reduce opportunity for the spread of disease to children through adults employed in centers and family day care homes.

3. Related Legislation. AB 1667 (Williams) replaced current mandatory tuberculosis (TB) testing for school employees and volunteers with a TB risk assessment administered by a health care provider.

4. Prior Legislation.

1. SB 277 (Pan and Allen), Chapter 35, Statutes of 2015, eliminates the personal belief exemption from the requirement that children receive specified vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school or day care center.

2. AB 2109 (Pan) Chapter 821, Statutes of 2012, requires that if a child requests an exemption from the school vaccination requirement due to a personal belief, that an additional form issued by DPH must accompany a letter or affidavit for a personal belief exemption. The form must include a signed attestation from a health care practitioner that he or she provided information regarding the benefits and risks of the immunization and the health risks of the communicable diseases. 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.”

5. Support. This bill is sponsored by the Health Officers Association of California and supported by numerous health care providers, teachers, the Child Care Law Center, the March of Dimes California chapter, and other groups.

6. Opposition. Several groups opposed to vaccination mandates, and hundreds of such individuals, have written in opposition.

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

Date of Hearing: July 14, 2015

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Kansen Chu, Chair

SBPCA Bill Id:SB 792

Author:(Mendoza) – As Amended Ver:July 2, 2015

SENATE VOTE: 34-3

SUBJECT: Day care facilities: immunizations: exemptions.

SUMMARY: Requires day care center and family day care home employees to be immunized against influenza, pertussis and measles.

Specifically, this bill:

1. Prohibits the employment of a person at a day care center or a family day care home, commencing September 1, 2016, if he or she has not been immunized against influenza, pertussis and measles.

2. Requires each employee to receive an influenza vaccination between August 1 and December 1 of each year, except when an exemption applies.

3. Exempts a day care center or family day care home employee from the immunization requirements provided for in this bill if any of the following apply:

   1. The person submits a written statement from a licensed physician declaring that because of the person’s physical condition or medical circumstances, immunization is not safe;

2. The person submits a written statement from a licensed physician providing that the person has evidence of current immunity to influenza, pertussis, and measles;

3. The person submits a written declaration that he or she has declined the influenza vaccination. This exemption applies only to the influenza vaccine; or

4. The person was hired after December 1 of the previous year and before August 1 of the current year. This exemption applies only to the influenza vaccine.

1. Adds providing evidence of current immunity to influenza, pertussis, and measles, as specified, to the current list of requirements employees of day care centers and family day care homes must meet as conditions of new or continued employment, beginning September 1, 2016.

EXISTING LAW:

1. Establishes the Child Day Care Facilities Act with the Department of Social Services (DSS) as the licensing entity for child care centers and family child care homes, to ensure that working families have access to healthy and safe child care providers and that child care programs contribute positively to a child's emotional, cognitive, and educational development, and are able to respond to, and provide for, the unique characteristics and needs of children. (HSC 1596.70 et seq.)

2. Defines a “day care center” to mean any child day care facility other than a family day care home, including infant centers, preschools, extended day care facilities, and school age child care centers, as defined. (HSC 1596.76)

3. Defines a “family day care home” as a home that regularly provides care, protection, and supervision for 14 or fewer children, in the provider’s own home, for periods of less than 24 hours per day, while the parents or guardians are away, and is either a large family day care home or a small family day care home, as specified. (HSC 1596.78)

4. Allows a day care center licensee 30 days after the employment of a staff person or enrollment of a child to secure records requiring information from sources not in the control of the licensee or employee, such as physician examinations, immunization confirmations, or proof of educational qualifications. An extension can be granted where the licensee can demonstrate that further delays are beyond the control of the licensee. (HSC 1597.05)

5. Permits a person to be hired as a teacher in a day care center if he or she is at least 18 years of age, possesses a regional occupation program certificate of training in child care occupations, as defined, and has completed at least 95 hours of classroom instruction in child care and development and child care occupations and at least 150 hours in supervised field experience in a licensed day care center or comparable group child care program. (HSC 1597.055)

6. Requires family day care home to apply to DSS for licensure and to submit documentation related to financial security, disaster planning, fire safety, and both fingerprint and tuberculosis clearances for any adult in the home when children are present. (HSC 1597.54)

7. Requires DSS to perform random inspections each year in no fewer than 20% of licensed facilities not subject to annual inspections, including day care centers and family day care homes. Provides that this percentage shall increase by 10% if the total citations issued by the department exceeds the previous year by 10%. Requires DSS to visit every facility no less than every 5 years. (HSC 1597.09 and 1597.55a)

8. Establishes within the state Communicable Disease Prevention and Control Act specific immunization requirements for educational and child care facilities and prohibits the governing authority of a school or other institution from unconditionally admitting any person as a pupil of private or public elementary or secondary schools, child care centers, day nurseries, nursery schools, family day care homes, or development centers, unless, prior to first admission to that institution, he or she has been fully immunized against diphtheria, Haemophilus influenzae type b (Hib), measles, mumps, pertussis (whooping cough), poliomyelitis, rubella, tetanus, hepatitis b (except after 7th grade), and varicella (chickenpox). (HSC 120325)

9. Permits the Department of Public Health (DPH) to add to the aforementioned list any other disease deemed appropriate, taking into consideration the recommendations of the Advisory Committee on Immunization Practices of the United States Department of Health and Human Services (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians. (HSC 120325)

10. Waives the immunization requirement if the child’s parent, guardian or the adult who has assumed responsibility for the child’s care and custody files a letter with the governing authority stating that the immunization is contrary to his or her beliefs, as specified. (HSC 120365)

11. Waives the immunization requirement if the child’s parent or guardian files a written statement by a licensed physician to the effect that the physical condition of the child or medical circumstances relating to the child are such that immunization is not considered safe. Requires the statement to indicate the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization. (HSC 120370)

12. Requires as of July 1, 2007, that the state enforce a requirement for each general acute care hospital, in accordance with the Centers for Disease Control guidelines, to take all of the following actions:

1. Annually offer onsite influenza vaccinations, if available, to all hospital employees at no cost to the employee. Each general acute care hospital shall require its employees to be vaccinated, or if the employee elects not to be vaccinated, to declare in writing that he or she has declined the vaccination;

2. Institute respiratory hygiene and cough etiquette protocols, develop and implement procedures for the isolation of patients with influenza, and adopt a seasonal influenza plan; and

3. Revise an existing or develop a new disaster plan that includes a pandemic influenza component. The plan shall also document any actual or recommended collaboration with local, regional, and state public health agencies or officials in the event of an influenza pandemic. (HSC 1288.7)

13. Requires, within the California Code of Regulations, that employers make specified vaccine doses, including seasonal influenza vaccine, measles, mumps, and rubella vaccine, varicella vaccine, and tetanus-diphtheria-acellular pertussis (Tdap) vaccine available to all susceptible healthcare workers, as defined, with occupational exposure. Requires employers to ensure that employees who decline a recommended and offered vaccination sign the declination statement. Applies this requirement to hospitals, skilled nursing facilities, clinics, medical offices and other outpatient medical facilities, among others. Exempts outpatient medical facilities whose policy is not to diagnose or treat aerosol transmissible diseases from complying with this standard if they meet certain other conditions. (CCR Title 8 §5199(h)(5))

14. Requires, within the California Code of Regulations, that health employers make the seasonal influenza vaccine available to all employees at hospitals, skilled nursing facilities, clinics, medical offices and specified outpatient medical facilities who have occupational exposure to the flu, and to ensure that each employee who declines to accept the seasonal flu vaccine signs a statement of declination. (CCR Title 8 §5199(h)(10))

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

COMMENTS:

Child care: Among other supports, the state’s system of child care and development programs accommodates parents by ensuring their children are served in a healthy and safe environment while they are at work, in training or seeking employment, and it grants families access to programs that will help children with their social, emotional, educational and physical development. General child care and development programs are funded with federal and state dollars, and serve children from birth through 12 years of age.

The California Child Day Care Facilities Act governs the licensure and operation of child day care centers and family day care homes. This law and the associated regulations found in Title 22 of the California Code of Regulations establish general health and safety requirements, staff-to-child ratios, and provider training requirements. The Community Care Licensing Division (CCLD) of DSS is responsible for licensing and monitoring the state’s 10,453 day care centers, which, as of June 30, 2014, provided 588,058 child care slots. CCLD is required to conduct unannounced site visits of all licensed child day care facilities and homes. At the very least, these facilities and homes must be visited no less frequently than once every five years. CCLD also conducts annual visits of facilities with poor histories of compliance and those that are required to have yearly visits by federal law. Additionally, 30% of those facilities not required to be inspected yearly are randomly selected for annual inspection. The 2015-16 budget adopted further supports and reforms, including enacting upcoming changes to the frequency of inspections: starting in January 2017, DSS will increase inspections to once every three years for all facilities.

Child immunizations: SB 277 (Pan), Chapter 35, Statutes of 2015, was recently signed into law to, as of January 1, 2016, eliminate the personal belief exemption 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. Even before the introduction and passage of that bill, immunization coverage among two- to four-year-olds in licensed child care settings was greater than or equal to 94% percent for each vaccine according to a 2014-15 child care immunization assessment conducted by the California Department of Public Health (DPH). (This survey was conducted in 88% of California’s licensed child care facilities.)

Adult immunizations: The Advisory Committee on Immunization Practices (ACIP), within the Centers for Disease Control and Prevention (CDC), develops recommendations for the use of vaccines to control diseases in the U.S. One of the ACIP’s many charges is to annually review the recommended schedule of vaccines for adults, which was recently completed for 2015 and then approved by ACIP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Nurse-Midwives.¹ According to the ACIP’s charter:

“The committee also provides recommendations on contraindications and precautions for use of the vaccine and related agents and provides information on recognized adverse events. Committee deliberations on use of vaccines to control disease in the U.S. shall include consideration of disease epidemiology and burden of disease, vaccine efficacy and effectiveness, vaccine safety, economic analyses and implementation issues.”

The U.S. Department of Health and Human Services released a draft of its National Adult Immunization Plan in February of this year, which describes the nation’s low adult vaccination rates and emphasizes the importance of vaccines in improving overall quality of life and saving lives. The four key goals of the five-year plan are to: strengthen the adult immunization infrastructure; improve access to adult vaccines; increase community demand for adult immunizations; and foster innovation in adult vaccine development and vaccination-related technologies. Within each of the four goals are objectives that include: reducing financial barriers for individuals who receive vaccines routinely recommended for adults, increasing the use of Immunization Information Systems and Electronic Health Records to collect and track adult immunization data, and other objectives that promote positive societal impacts.

Employee vaccination requirements in other states: A CDC database tracks state law requirements for the vaccination of health care workers. Twelve states have some sort of vaccination requirement, and some states, including California, require employers to offer vaccines to their health care staff under certain exposure conditions. Most states with required vaccinations for health care workers include exemptions for personal beliefs; some, such as New York and New Mexico do not. Additionally, in many states where vaccinations are mandated, only certain ones are required, the most predominant of which are the Measles, Mumps and Rubella vaccines.

Current licensing requirements for employees: Licensing standards and provider and employee requirements for all licensed child care settings throughout the state are outlined within Title 22 of the California Code of Regulations. Pursuant to those regulations, all day care center and family day care home providers and employees are already required to be clear of tuberculosis based on a test performed not more than one year before or seven days after employment in the child care setting. As with the requirements currently set forth in statute and regulations related to child care licensing, CCLD licensing program analysts (LPAs) will need to verify compliance with the immunization requirements included in this bill through a review of records during licensing visits to a day care center or family day care home.

Need for this bill: According to the author, “Children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease (community immunity). This bill will protect children in day care by requiring those who care for them to maintain immunity. Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and perhaps even be fatal in an infant or an individual with a suppressed immune system. Last year in California, ten children died of influenza. During the last major pertussis outbreak in 2010, there were 9,000 cases of whooping cough and ten infant deaths. We have also seen a resurgence of measles, which can cause hospitalization and lifetime complications, including deafness. Out of every 1,000 people that contract measles, one or two will die, even with the best standard of care. By requiring vaccination for pre-school workers, vulnerable children will be “cocooned” from potentially serious illness, and day care centers will be a safe and healthy place for our little ones to learn and play.”

Support: The Child Care Law Center explains the everyday impact of the current lack of vaccination requirements for child care providers, stating, “Child Care Law Center receives questions from child care providers who ask about whether they can require their employees to get vaccinated against diseases that are most harmful to children. They have serious concerns about the health of the babies and other children with medical conditions in their care who cannot obtain vaccinations. Child care providers are upset when they find out that they cannot help protect unimmunized children from getting certain communicable diseases from their staff.”

Opposition: Your Family Your Choice writes, “Passing this bill would mean endangering the field of child care by reducing an already threatened commodity of otherwise qualified employees. The only way these individuals could avoid the health risk of vaccination is to leave this field of work altogether, further draining the already small pool of qualified candidates for employment.”

Staff Comments: While access to vaccines, including cost barriers, contraindications for pregnant women, and difficulties proving immunization to certain diseases are natural concerns for the child care workforce and have been enumerated by individuals concerned with the implications of this bill, a number of factors help decrease the overall impact.

Proof of immunization: This bill is not prescriptive with respect to how a person will work with his or her physician to provide evidence of current immunity, which offers more flexibility than having to locate old immunization records or simply revaccinate. According to the author’s office, disease immunity information can be gathered through the results of an antibody titers test, which tests the level of antibodies in a person’s blood. Instead of vaccination, a day care teacher can submit to a simple blood test to verify immunity. (The test could also reveal the need for a vaccine booster to continue immunity). To the extent information has been entered, a physician could also search the California Immunization Registry, which is a secure, statewide immunization information system.

Cost: According to the sponsor of this bill, the Health Officers Association of California, out-of-pocket expenses for individuals required to comply with this bill should be minimal. Under the federal Patient Protection and Affordable Care Act, and in the spirit of prevention, most insurance plans are required to cover vaccinations for all ACIP-recommended vaccines free of copayment or coinsurance. Additionally, local health departments offer vaccines at no cost or at a discounted rate. For a prospective day care teacher without health insurance and without access to a local health department, measles vaccines cost around $80, the pertussis vaccine costs around $50 and flu shots can cost around $15. While the flu shot – if the employee doesn’t opt out of it – is required to be received annually, the other two vaccines are recommended on a prolonged schedule, therefore reducing the annual costs to comply with this bill.

Pregnancy: Of particular concern to opponents of this bill is how it will affect women who are pregnant or could become pregnant. While the CDC does cite a contraindication for the measles vaccine for pregnant women, it is important to remember the manner in which vaccinations are provided. Prior to vaccination, a conversation can and should be had with the administering health care professional about a woman’s potential pregnancy. Additionally, the medical condition exemption provided for in this bill should cover this contraindication and waive the vaccination requirement.

Delayed implementation: Because the requirements of this bill will not be implemented until September of 2016, day care teachers have time to comply and licensees have time to work with their local health departments and disseminate information to their current and prospective employees.

Still, this bill will establish a first of its kind requirement for a particular workforce to be immunized with very few opportunities to decline. While this bill seeks to further protect children by establishing immunization requirements for workers in day care centers and family child care homes, acknowledging the devastating impact certain preventable diseases can have on young children, it is not based on information showing high levels of unimmunized child care teachers. The Committee may wish to have the author further explain the rationale for applying this requirement to a particular group of individuals and why the requirements are more stringent than what exists for other professionals.

RECOMMENDED TECHNICAL AMENDMENT:

One of the conditions for exemption from the immunization requirement established in this bill is submission of a written statement from a licensed physician providing that the person has evidence of current immunity to influenza, pertussis, and measles. However, while this language is clear for day care centers, the corresponding provision that this bill adds to Health & Safety Code Section 1597.622 specifies that an exemption can be given for “a written statement by a licensed physician providing that the person has evidence of current immunity to one or more of the diseases described in subdivision (a).” In order to provide consistency and greater clarity around the requirements for the exemption, committee staff recommends the following technical amendment to page 5 of the bill:

21 (2) The person submits a written statement by a licensed

22 physician providing that the person has evidence of current

23 immunity to one or more of the diseases described in subdivision

24 (a).

PRIOR LEGISLATION:

SB 277 (Pan and Allen), Chapter 35, Statutes of 2015, eliminates the personal belief exemption from the requirement that children receive specified vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school or day care center.

SB 2109 (Pan) Chapter 821, Statutes of 2012, requires that if a child requests an exemption from the school vaccination requirement due to a personal belief, that an additional form issued by DPH must accompany a letter or affidavit for a personal belief exemption. The form must include a signed attestation from a health care practitioner that he or she provided information regarding the benefits and risks of the immunization and the health risks of the communicable diseases. 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.”

AB 2580 (Arambula) 2008, would have required pupils entering the seventh grade to be fully immunized against pertussis by receiving any necessary adolescent booster immunization. Died on the Senate Appropriations Committee suspense file.

SB 676 (Ridley-Thomas) 2007, would have required pupils entering the seventh grade to be fully immunized against pertussis. Died on the Assembly Appropriations Committee suspense file.

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

AB 2386 (Leach) 2000, would have required adults working at an adult residential care facility to be vaccinated against the flu and pneumococcal viruses, and provided a personal belief exemption to the mandate. Died in the Assembly Health Committee.

SECOND COMMITTEE OF REFERENCE. This bill was previously heard in the Assembly Health Committee on June 30, 2015 and was approved on a 17-1 vote.

REGISTERED SUPPORT / OPPOSITION:

Support

Health Officers Association of California (HOAC), sponsor

Alameda County Board of Supervisors

American Academy of Pediatrics

American Nurses Association\California (ANA\C)

California Academy of Family Physicians

California Academy of Preventive Medicine (CAPM)

California Federation of Teachers (CFT)

California Hospital Association (CHA)

California Medical Association (CMA)

California Primary Care Association (CPCA)

California Public Health Association-North (CPHA-N)

Child Care Law Center

Children Now

County Health Executives Association of CA (CHEAC)

First 5 California

Knowledge Universe

Los Angeles County Board of Supervisors

March of Dimes California Chapter

National Association of Social Workers, CA (NASW-CA)

Santa Clara County Board of Supervisors

Opposition

Educate. Advocate.

California Coalition for Health Choice

Your Family Your Choice

440 Individuals

Analysis Prepared by: Myesha Jackson / HUM. S. / (916) 319-2089

Date of Hearing: June 30, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

SBPCA Bill Id:SB 792

Author:(Mendoza) – As Amended Ver:June 22, 2015

SENATE VOTE: 34-3

SUBJECT: Day care facilities: immunizations: exemptions.

SUMMARY: Prohibits, after September 1, 2016, a day care center or a family day care home from employing any person who has not been immunized against measles, pertussis, and influenza. Specifies circumstances under which a person would be exempt from the immunization requirement based on medical safety, current immunity, or employee declination. Specifically, this bill:

1. Prohibits a person from being employed at a day care center or a family day care home if he or she has not been immunized against measles and pertussis, and has received an annual seasonal influenza vaccine.

2. Exempts a person from this requirement only under the following circumstances:

1. The person submits a written statement from a licensed physician declaring that immunization is not safe because of the person's physical condition or medical circumstances. Requires the statement to indicate the probable duration of the medical condition or circumstances that contraindicate immunization;

2. The person submits a written statement from a licensed physician providing that the person has evidence of current immunity to the diseases included on the immunization schedule; or,
   
   

3. The person submits a written declaration that he or she has declined the influenza vaccination. This exemption applies only to the influenza vaccine; or,
   
   

4. The person is temporarily exempt from influenza vaccination if hired after December 1, until August 1.

3. Makes conforming changes to statute defining the qualifications for day care center teachers and for licensure as a family day care center, including:
   
   

   1. Makes provision of the evidence of current immunity, as defined, a condition of hiring a teacher in a day care center; and,

2. Requires as a condition of licensure by the California Department of Social Services (DSS) that family day care home applicants must provide evidence of current immunity, as defined, for the applicant and any other person who provides care and supervision to the children.

EXISTING LAW:

1. Establishes the Child Day Care Facilities Act with DSS as the licensing entity for child care centers and family child care homes, states legislative intent to provide a comprehensive, quality system for licensing child day care facilities to ensure a quality day care environment and that good quality child day care services are an essential service for working parents.

2. Defines a “child day care facility” as a facility that provides nonmedical care to children under 18 years of age in need of personal services, supervision, or assistance on less than a 24-hour basis, as specified, and includes in that definition day care centers, employer-sponsored child care centers, and family day care homes.

3. Defines a “day care center” to mean any child day care facility other than a family day care home, including infant centers, preschools, extended day care facilities, and school age child care centers, and defines a “family day care home” as a home that regularly provides care, protection, and supervision for 14 or fewer children, in the provider's own home, as defined.

4. Establishes within the state Communicable Disease Prevention and Control Act specific immunization requirements for educational and child care facilities and prohibits the governing authority of a school or other institution from unconditionally admitting any person as a pupil of private or public elementary or secondary schools, child care centers, day nurseries, nursery schools, family day care homes, or development centers, unless, prior to first admission to that institution, he or she has been fully immunized against diphtheria, Haemophilus influenzae type b (Hib), measles, mumps, pertussis (whooping cough), poliomyelitis, rubella, tetanus, hepatitis b (except after 7th grade), and varicella (chickenpox).

5. Permits the Department of Public Health (DPH) to add to the list in 4) above 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.

6. Waives the immunization requirement if the child's parent or guardian files a written statement by a licensed physician to the effect that the physical condition of the child or medical circumstances relating to the child are such that immunization is not considered safe. Requires the statement to indicate the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization.

7. Waives the immunization requirement if the child's parent, guardian or the adult who has assumed responsibility for the child's care and custody files a letter with the governing authority stating that the immunization is contrary to his or her beliefs (commonly referred to as a “personal belief exemption” or PBE).

8. Permits a person to be hired as a teacher in a day care center if he or she is at least 18 years of age, possesses a regional occupation program certificate of training in child care occupations, as defined, and has completed at least 95 hours of classroom instruction in child care and development and child care occupations and at least 150 hours in supervised field experience in a licensed day care center or comparable group child care program.

9. Requires a family day care home to apply to DSS for licensure and to submit documentation related to financial security, disaster planning, fire safety, and both fingerprint and tuberculosis clearances for any adult in the home when children are present.
   
   

10. Allows a day care center licensee 30 days after the employment of a staff person or enrollment of a child to secure records requiring information from sources not in the control of the licensee or employee, such as physician examinations, immunization confirmations, or proof of educational qualifications. An extension can be granted where the licensee can demonstrate that further delays are beyond the control of the licensee.

11. Requires as of July 1, 2007, that the state enforce a requirement for each general acute care hospital, in accordance with the CDC guidelines, to take all of the following actions:

1. Annually offer onsite influenza vaccinations, if available, to all hospital employees at no cost to the employee. Each general acute care hospital shall require its employees to be vaccinated, or if the employee elects not to be vaccinated, to declare in writing that he or she has declined the vaccination;

2. Institute respiratory hygiene and cough etiquette protocols, develop and implement procedures for the isolation of patients with influenza, and adopt a seasonal influenza plan; and

3. Revise an existing or develop a new disaster plan that includes a pandemic influenza component. Requires the plan to also document any actual or recommended collaboration with local, regional, and state public health agencies or officials in the event of an influenza pandemic.

12. Requires, under the current regulation, employers to make available to all susceptible healthcare workers with occupational exposure specified vaccine doses, including seasonal influenza vaccine, measles, mumps, and rubella vaccine, varicella vaccine, and tetanus-diphtheria-acellular pertussis (Tdap) vaccine. Requires employers to ensure that employees who decline a recommended and offered vaccination sign the declination statement. Applies this requirement to hospitals, skilled nursing facilities, clinics, medical offices and other outpatient medical facilities, among others. Exempts outpatient medical facilities whose policy is not to diagnose or treat aerosol transmissible diseases from complying with this standard if they meet certain other conditions.

13. Requires, under current regulation, health facility employers to make seasonal influenza vaccine available to all employees at hospitals, skilled nursing facilities, clinics, medical offices and specified outpatient medical facilities who have occupational exposure to the flu, and to ensure that each employee who declines to accept the seasonal flu vaccine signs a statement of declination.

14. Under the federal Patient Protection and Affordable Care Act, requires all Health Insurance Marketplace plans and most other private insurance plans to cover, free of copayment or coinsurance, vaccinations for all ACIP-recommended vaccines.

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease. The author states that this bill will protect children in day care by requiring those who care for them to maintain immunity.

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 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. Vaccines 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.

3. YOUNG CHILDREN ARE PARTICULARLY AT RISK. Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and be potentially fatal for infants or individuals with suppressed immune systems. Importantly, many vaccines require multiple doses before a child is protected against the disease, and children in day care settings are often too young to complete the recommended series of vaccinations.

   1. Pertussis is a highly contagious bacterial disease that can be spread by coughing. People with pertussis have severe coughing attacks that can last for months. Infants too young for vaccination are at greatest risk for life-threatening cases of pertussis. Pertussis vaccinations are given starting at two months of age, but multiple doses are required before the child is considered fully immunized. According to DPH, during a major pertussis outbreak in 2010, there were 9,000 cases of pertussis resulting in 10 infant deaths. In 2014, there were 11,114 reported cases of whooping cough with three infant deaths. As of June 1, 2015 there have been 2,552 new cases of pertussis in California this year. Sixty-two infants younger than four months of age have been hospitalized and one death was reported in an infant that contracted pertussis at three weeks of age.

   2. Measles is a highly contagious viral disease, and is considered the most deadly of all childhood rash/fever illnesses. It is recommended that children receive their first measles vaccination at 12 to 15 months; to be most effective, a second dose is recommended at four to six years. Measles is particularly dangerous for babies and young children. From 2001-13, 28% of children younger than five years old who had measles had to be treated in the hospital. For some children, measles can lead to pneumonia, lifelong brain damage, deafness, or death. According to the CDC, the United States declared that measles was eliminated from this country in 2000; however, 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 December 2014 outbreak in California, which is one of five outbreaks so far this year reported by the CDC.

3. Influenza, or flu, is a contagious respiratory illness caused by influenza viruses. The CDC recommends a yearly flu vaccine for everyone six months of age and older as the first and most important step in protecting against this serious disease. Because there are many different flu viruses, the flu vaccine is redesigned annually to protect against the flu strains that research indicates will cause the most illness during the flu season. Last year in California, 10 children died of influenza. According to the CDC's nationwide surveillance, 142 children passed away during the 2014-15 flu season due to complications with the flu, bringing the total of pediatric deaths since 2004 to over 1,000.

1. COMMUNITY IS LOCAL. 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 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 masks 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 of the community that a child interacts with on a daily basis, such as family members, teachers, and other students, is more relevant than a statewide number.

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. In day care settings, small classroom size and low teacher-to-student ratio has raised concerns that teachers and workers should also be required to be immunized in order to ensure the community interacting daily with very young children maintains a vaccination level high enough to protect community immunity.

5. ADULT VACCINE REQUIREMENTS IN THE HEALTHCARE WORKFORCE. State law mandates that each general acute care hospital require its employees to be vaccinated against influenza annually. State law additionally mandates that all employees in general acute care hospitals be offered a free influenza vaccine annually by their employer, if the vaccine is available. The California Code of Regulations additionally requires employers at hospitals, skilled nursing facilities, clinics, medical offices and specified outpatient medical facilities to make available an annual influenza vaccine for employees who have occupational exposure to the flu. In each of these settings, the employee may elect not to be vaccinated, and file a declaration in writing that he or she has declined the vaccination.

State regulations require the same employers above to make available to all susceptible healthcare workers who have occupational exposure to specific airborne illnesses, which include seasonal influenza, measles, mumps, and rubella, varicella, and the Tdap vaccine. Employers are required to ensure that employees who decline to accept a vaccination that is recommended and offered sign a declination statement.

6. ADULT WORKER VACCINATIONS IN OTHER STATES. According to the CDC, 12 states have requirements for some vaccination of healthcare workers. Some states, including California, require employers to offer vaccines to their healthcare staff under certain exposure conditions. Most states with required vaccinations for healthcare workers include exemptions for personal beliefs: Alabama, New Mexico and several others do not. Many states only mandate certain vaccines - the most prominent being the Measles, Mumps and Rubella vaccine. Some states have various requirements for daycare workers. In 2014, Texas passed a law requiring child-care facilities to develop and implement a policy concerning vaccination of employees. Colorado requires staff at day care centers be current for all immunizations routinely recommended for adults by their health care provider.

7. SUPPORT. The Health Officers Association of California writes that given that child care workers have close, intimate contact with children who are unable to be fully immunized, it is important to ensure that these dedicated professionals are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases. The California Primary Care Association states that vaccines are a modern medical miracle, but they are only effective if people working with our vulnerable children are required to be vaccinated. Knowledge Universe states the U.S. is experiencing a multi-state outbreak of measles, and at one child care center alone this year, 12 infants became sick with the measles as this highly contagious illness spread from one infant to all other infants in the center. The Santa Clara County Board of Supervisors and other supporters state that it is important to ensure that child care professionals are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases.

8. OPPOSITION. The California Right to Life Committee states that this bill places an unwarranted burden on child care employees, as well as an unnecessary mandate that day care owners must enforce. California Coalition for Health Choice states that "this bill capitalizes on fears of a nonexistent public health crisis, discriminates against select groups, and offers no sound incentives to expand public health education." Your Family, Your Choice opposes the bill unless it is amended to include a personal belief or religious exemption. They also request amendments to exclude from the mandate caregivers who do not care for infants.

9. RELATED LEGISLATION. SB 277 (Pan and Allen) eliminates the non-medical exemptions from the requirement that children receive specified vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school or day care center. SB 277 was approved by the Assembly on June 25, 2015 by a vote of 46 - 30 and is currently pending concurrence of Assembly amendments in the Senate.

10. DOUBLE REFERRAL. This bill is double referred; upon passage in this Committee, this bill will be referred to the Assembly Human Services Committee.

11. POLICY COMMENT.

    1. Current law requires employers to collect and keep specific records for each new hire. This bill would require an annual review of employee records for influenza vaccination. The Committee may wish to consider whether this bill would require additional burden on employers to annually review employee files, remind employees about requirements, and keep track of documentation.

    2. The Department of Industrial Relations has, through regulation, created a standardized form that health care employees sign, and employers keep on file, when the employee declines offered vaccination. The Committee may wish to consider whether a standardized declination form would be useful for the child care industry as well.

12. SUGGESTED AMENDMENTS.

    1. The medical exemption in the bill, as drafted, may require the physician to disclose confidential medical information that could be protected by state and federal law. To address this privacy concern, the bill should be amended on page 2 as follows:

The person submits a written statement from a licensed physician declaring that because of the person’s physical condition or medical circumstances, immunization is not safe. The statement shall indicate the probable duration of the medical condition or circumstances that contraindicate immunization.

2. Technical Amendment: An incorrect cross-reference should be amended on page 3, line 22 of the bill as follows:

Commencing September 1, 2016, has provided evidence of current immunity, as described in paragraph (1) (2) of subdivision (b) of Section 1596.7995.

REGISTERED SUPPORT / OPPOSITION:

Support

Health Officers Association of California (sponsor)

Alameda County Board of Supervisors

American Academy of Pediatrics

American Nurses Association \ California

California Academy of Family Physicians

California Academy of Preventive Medicine

California Federation of Teachers

California Hospital Association

California Medical Association

California Public Health Association - North

California Primary Care Association

Child Care Law Center

Children Now

County Health Executives Association of California

First 5 California

Knowledge Universe

Los Angeles County Board of Supervisors

March of Dimes, California Chapter

National Association of Social Workers – California

Santa Clara County Board of Supervisors

Opposition

AWAKE California

California Right to Life Committee, Inc.

Canary Party - California

Educate. Advocate.

LifeWays North America (unless amended)

National Vaccine Information Center

Your Family, Your Choice (unless amended)

Hundreds of individuals

Analysis Prepared by: Dharia McGrew / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SB 792

Author: Mendoza (D)

Amended: 4/30/15

Vote: 21

SENATE HEALTH COMMITTEE: 8-0, 4/15/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Pan, Roth, Wolk

NO VOTE RECORDED: Nielsen

SENATE HUMAN SERVICES COMMITTEE: 3-0, 4/28/15

AYES: McGuire, Berryhill, Hancock

NO VOTE RECORDED: Liu, Nguyen

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SUBJECT: Day care facilities: immunizations: exemptions

SOURCE: Health Officers Association of California

DIGEST: This bill prohibits, commencing September 1, 2016, a person from being employed at a day care center or a day care home if he or she has not been immunized according to the schedule for routine adult immunizations, as recommended by the federal Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, with the exception of immunization against human papillomavirus.

ANALYSIS:

Existing law:

1. Permits a person to be hired as a teacher in a day care center if he or she is 18 years or older and meets certain educational requirements.

2. Requires family day care homes for children to apply to the Department of Social Services (DSS) for a license and requires applicants to file an application on forms furnished by DSS, as specified, and to include specified documentation related to finances, fire safety, employee fingerprints, and tuberculosis clearance.

3. Prohibits the governing authority of a school or other institution from unconditionally admitting any person as a pupil of private or public elementary or secondary schools, child care centers, day nurseries, nursery schools, family day care homes, or development centers, unless, prior to 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.

4. Permits the Department of Public Health (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.

5. Waives the above immunization requirements 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 or medical circumstances relating to the child are such that immunization is not considered safe. Requires the statement to indicate the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization.

6. Waives the above immunization 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 with the governing authority stating that the immunization is contrary to his or her beliefs (commonly referred to as a “personal belief exemption” or “PBE.”)

7. Requires a separate form prescribed by DPH to accompany a PBE. Requires the form to include:

   1. A signed attestation from a 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. Requires the attestation to be signed within six months of the date when the person first becomes subject to the immunization requirement for which the PBE is being sought.

   2. 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 received the information provided by the health care practitioner pursuant to a) above. Requires the statement to be signed within six months of the date when the person first becomes subject to the immunization requirements.

8. 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 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. Prohibits, commencing September 1, 2016, a person from being employed at a day care center or a day care home if he or she has not been immunized according to the schedule for routine adult immunizations, as recommended by ACIP, with the exception of immunization against human papillomavirus (HPV).

2. Exempts a person from this requirement if the person submits:

1. A written statement from a licensed physician declaring that because of the person’s physical condition or medical circumstances, immunization is not safe. Requires the statement to indicate the probable duration of the medical condition or circumstances that contraindicate immunization;

2. A written statement from a licensed physician providing that the person has evidence of current immunity to the diseases included on the immunization schedule; or

3. A written declaration that he or she has declined the influenza vaccination.

3. Places the immunization requirement above specifically on day care teachers.

4. Requires, as a condition of licensing by DSS commencing September 1, 2016, family day care home applicants to provide evidence of current immunity pursuant to 1) above for the applicant and any other person who provides care and supervision to the children.

Comments:

1. Author’s statement. According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease (community immunity). This bill will protect children in day care by requiring those who care for them to maintain immunity. Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and perhaps even be fatal in an infant or an individual with a suppressed immune system. Other diseases in the ACIP schedule include very serious conditions, formerly under control, that have resurfaced in recent years, including pertussis and measles. By requiring vaccination for pre-school workers, vulnerable children will be “cocooned” from potentially serious illness, and day care centers will be a safe and healthy place for our little ones to learn and play.

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. Vaccines 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.

3. ACIP. The ACIP consists of 15 experts who are voting members and are responsible for making vaccine recommendations. The Secretary of the U.S. Department of Health and Human Services selects these members after an application, interview, and nomination process. Fourteen of the members have expertise in vaccinology, immunology, pediatrics, internal medicine, nursing, family medicine, virology, public health, infectious diseases, and/or preventive medicine; one member is a consumer representative who provides perspectives on the social and community aspects of vaccination. 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 vaccine-preventable diseases and to increase the safe usage of vaccines and related biological products.

ACIP, along with AAP, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, approved the 2015 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. California Vaccination Rates. According to an August 2014 DPH fact sheet, vaccination coverage in California is at or near all-time high levels. DPH states that the implementation of current vaccine requirements has been effective in maintaining greater than or equal to 92 percent immunization coverage among children in licensed child care facilities and kindergartens. DPH would like immunization rates to be as close to 100 percent as possible, and is using national Healthy People 2020 objectives as a benchmark to monitor progress. These objectives include: toddlers/pre-school: 90 percent rate for four doses of DTaP, 3 or 4 doses of Hib vaccine, 3 doses of hepatitis b vaccine, 1 dose of MMR, 3 doses of polio vaccine, and one dose of varicella vaccine; kindergarteners: 95 percent rate for 4 doses DTaP, 2 MMR, 3 polio vaccine, 3 hepatitis b vaccine, and 2 doses of varicella vaccine; and for 13 to 15 year olds: 80 percent Tdap vaccination rate. The DPH Immunization Branch maintains data on its website related to vaccination rates and is searchable statewide and by school (kindergarten and seventh grade rates) and child care facility. This year, 89.4 percent of the 434,922 children aged two to five years enrolled in reporting child care facilities received all required immunizations (4+ DTP, 3+ Polio, 1+ MMR, 1+ Hib, 3+ Hep B, and 1+ Vari or physician-documented varicella disease), a 0.1 percent increase from the prior year. ‘Conditional’ entrants (children in process to be fully vaccinated but not yet having all required vaccinations), decreased by 0.1 percent this past year. There were 2,734 (0.56 percent) children with permanent medical exemptions (PMEs) and 12,981 (2.67 percent) with PBEs. Children with PBEs decreased from 2.94 percent this past year. For all facilities, immunization coverage was greater than or equal to 94 percent for each vaccine this year.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 5/18/15)

Health Officers Association of California (sponsor)

American Academy of Pediatrics California

American Nurses Association, California

California Academy of Family Physicians

California Academy of Preventive Medicine

California Chapter National Association of Social Workers

California Federation of Teachers

California Hospital Association

California Primary Care Association

California Public Health Association – North

Child Care Law Center

Children Now

County Health Executives Association of California

First 5 California

Knowledge Universe

Los Angeles County Board of Supervisors

March of Dimes California Chapter

Santa Clara County Board of Supervisors

OPPOSITION: (Verified 5/18/15)

AWAKE California

California Chiropractic Association

California Right to Life Committee, Inc.

Educate. Advocate.

Prepared by: Melanie Moreno / HEALTH /

5/20/15 12:06:05

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: SB 792

SUBJECT: Day care facilities: immunizations: exemptions

SUMMARY:

1. Prohibits, commencing September 1, 2016, a person from being employed at a day care center or a day care home if he or she has not been immunized according to the schedule for routine adult immunizations, as recommended by the federal Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, with the exception of immunization against human papillomavirus.

Existing law:

1. Permits a person to be hired as a teacher in a day care center if he or she is 18 years or older and meets certain educational requirements.

2. Requires family day care homes for children to apply to the Department of Social Services (DSS) for a license and requires applicants to file an application on forms furnished by DSS, as specified, and to include specified documentation related to finances, fire safety, employee fingerprints, and tuberculosis clearance.

3. Prohibits the governing authority of a school or other institution from unconditionally admitting any person as a pupil of private or public elementary or secondary schools, child care centers, day nurseries, nursery schools, family day care homes, or development centers, unless, prior to 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.

4. Permits the Department of Public Health (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.

5. Waives the above immunization requirements 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 or medical circumstances relating to the child are such that immunization is not considered safe. Requires the statement to indicate the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization.

6. Waives the above immunization 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 with the governing authority stating that the immunization is contrary to his or her beliefs (commonly referred to as a “personal belief exemption” or “PBE.”)

7. Requires a separate form prescribed by DPH to accompany a PBE. Requires the form to include:

1. A signed attestation from a 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. Requires the attestation to be signed within six months of the date when the person first becomes subject to the immunization requirement for which the PBE is being sought.

1. 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 received the information provided by the health care practitioner pursuant to a) above. Requires the statement to be signed within six months of the date when the person first becomes subject to the immunization requirements.

8. 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 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:

2. Prohibits, commencing September 1, 2016, a person from being employed at a day care center or a day care home if he or she has not been immunized according to the schedule for routine adult immunizations, as recommended by ACIP, with the exception of immunization against human papillomavirus (HPV).

3. Exempts a person from this requirement only under either of the following circumstances:

1. The person submits a written statement from a licensed physician declaring that because of the person’s physical condition or medical circumstances, immunization is not safe. Requires the statement to indicate the probable duration of the medical condition or circumstances that contraindicate immunization; or,

2. The person submits a written statement from a licensed physician providing that the person has evidence of current immunity to the diseases included on the immunization schedule.

4. Places the immunization requirement above specifically on day care teachers.

5. Requires, as a condition of licensing by DSS commencing September 1, 2016, family day care home applicants to provide evidence of current immunity pursuant to 1) above for the applicant and any other person who provides care and supervision to the children.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, children in day care settings have close, intimate contact with each other and with the staff who work there. Many of these children are too young to be fully immunized against potentially serious communicable diseases. Children who are too young to be vaccinated rely on those around them to be immunized to prevent the spread of disease (community immunity). This bill will protect children in day care by requiring those who care for them to maintain immunity. Some diseases, such as the flu, cause only a relative inconvenience to healthy adults. However, this same disease can require hospitalization and perhaps even be fatal in an infant or an individual with a suppressed immune system. Other diseases in the ACIP schedule include very serious conditions, formerly under control, that have resurfaced in recent years, including pertussis and measles. By requiring vaccination for pre-school workers, vulnerable children will be “cocooned” from potentially serious illness, and day care centers will be a safe and healthy place for our little ones to learn and play.

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. Vaccines 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.

3. ACIP. The ACIP consists of 15 experts who are voting members and are responsible for making vaccine recommendations. The Secretary of the U.S. Department of Health and Human Services selects these members after an application, interview, and nomination process. Fourteen of the members have expertise in vaccinology, immunology, pediatrics, internal medicine, nursing, family medicine, virology, public health, infectious diseases, and/or preventive medicine; one member is a consumer representative who provides perspectives on the social and community aspects of vaccination. 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 vaccine-preventable diseases and to increase the safe usage of vaccines and related biological products.

ACIP, along with AAP, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, approved the 2015 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. California vaccination rates. According to an August 2014 DPH fact sheet, vaccination coverage in California is at or near all-time high levels. DPH states that the implementation of current vaccine requirements has been effective in maintaining greater than or equal to 92 percent immunization coverage among children in licensed child care facilities and kindergartens. DPH would like immunization rates to be as close to 100 percent as possible, and is using national  Healthy People 2020 objectives as a benchmark to monitor progress.  These objectives include: toddlers/pre-school: 90 percent rate for four doses of DTaP, 3 or 4 doses of Hib vaccine, 3 doses of hepatitis b vaccine, 1 dose of MMR, 3 doses of polio vaccine, and one dose of varicella vaccine; kindergarteners: 95 percent rate for 4 doses DTaP, 2 MMR, 3 polio vaccine, 3 hepatitis b vaccine, and 2 doses of varicella vaccine; and for 13 to 15 year olds: 80 percent Tdap vaccination rate. The DPH Immunization Branch maintains data on its website related to vaccination rates and is searchable statewide and by school (kindergarten and seventh grade rates) and child care facility. This year, 89.4 percent of the 434,922 children aged two to five years enrolled in reporting child care facilities received all required immunizations (4+ DTP, 3+ Polio, 1+ MMR, 1+ Hib, 3+ Hep B, and 1+ Vari or physician-documented varicella disease), a 0.1 percent increase from the prior year. ‘Conditional’ entrants (children in process to be fully vaccinated but not yet having all required vaccinations), decreased by 0.1 percent this past year. There were 2,734 (0.56 percent) children with permanent medical exemptions (PMEs) and 12,981 (2.67 percent) with PBEs. Children with PBEs decreased from 2.94 percent this past year. For all facilities, immunization coverage was greater than or equal to 94 percent for each vaccine this year.

5. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Committee on Human Services.

6. Related legislation. SB 277 (Pan and Allen) eliminates the personal belief exemption from the requirement that children receive specified vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school or day care center. SB 277 passed the Senate Health Committee by a vote of 6-2 on April 8, 2015 and is set for hearing on April 15, 2015 in the Senate Committee on Education.

7. Prior legislation. SB 2109 (Pan), Chapter 821, Statutes of 2012, requires, on and after January 1, 2014, a separate form prescribed by DPH to accompany a letter or affidavit for a PBE. Requires the form to include:

1. A signed attestation from a health care practitioner that indicates he or she provided information regarding the benefits and risks of the immunization and the health risks of the communicable diseases, as specified; and,

2. A written statement signed by the parent or guardian or an emancipated minor that indicates that the signer has received the information provided by the health care practitioner pursuant a) 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.”

AB 2064 (V. Manuel Pérez), of 2012, 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 the Assembly Appropriations Committee suspense file.

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.

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 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 the Assembly Appropriations Committee suspense file.

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. Support. The Health Officers Association of California writes that given that child care workers have close, intimate contact with children who are unable to be fully immunized, it is important to ensure that these dedicated professionals that are not inadvertently exposing children to potentially fatal, yet vaccine-preventable, childhood diseases. The California Primary Care Association states that vaccines are a modern medical miracle, but the are only effective if people working with our vulnerable children are required to be vaccinated. Knowledge Universe states the U.S. is experiencing a multi-state outbreak of measles, and at one child care center alone this year, 12 infants became sick with the measles as this highly contagious illness spread from one infant to all other infants in the center. March of Dimes states that they support this bill because it will help protect children in day cares from vaccine-preventable diseases but recommend that it be amended to allow for an exemption for medical reasons to be consistent with existing state law on immunizations.

9. Opposition. The California Right to Life Committee, Inc. states that it does not support governmental agencies interfering with private businesses in this circumstance as it would place an undue burden on small businesses.

SUPPORT AND OPPOSITION:

Support: Health Officers Association of California (sponsor)

American Academy of Pediatrics

California Academy of Family Physicians

California Chapter National Association of Social Workers

California Primary Care Association

Children Now

County Health Executives Association of California

Knowledge Universe

March of Dimes California Chapter

Oppose: AWAKE California

California Right to Life Committee, Inc.

Three individuals

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