Under existing law, each person between 6 and 18 years of age who is not otherwise exempt is subject to compulsory full-time education. Existing law requires each person subject to compulsory full-time education to attend the public full-time day school in which the residency of either the parent or legal guardian is located, except as specified. Existing law authorizes a school district, county office of education, or charter school to offer independent study courses to pupils in accordance with prescribed conditions, including, among others, that the courses are annually certified to be of the same rigor and educational quality as equivalent classroom-based courses.

Existing law prohibits the governing authority of a private or public elementary or secondary school, child care center, day nursery, nursery school, family day care home, or development center from unconditionally admitting any person as a pupil of one of those institutions, unless, before his or her admission to that institution, he or she has been fully immunized against various diseases. Existing law exempts pupils in a home-based private school and pupils enrolled in an independent study program and who do not receive classroom-based instruction from that prohibition.

This bill would authorize a pupil who does not meet those immunization requirements to enroll in an independent study program that does not require classroom-based instruction and that is outside of the geographic boundaries of the school district or county in which the pupil resides if the school district or county office of education of residence, or a charter school within the geographic boundaries of the school district or county of residence, does not offer an independent study program that does not require classroom-based instruction.

Existing law provides that community school and independent study average daily attendance shall be claimed by school districts, county superintendents of schools, and charter schools only for pupils who are residents of the county in which the apportionment claim is reported, or who are residents of a county immediately adjacent to the county in which the apportionment claim is reported.

This bill would additionally authorize independent study average daily attendance to be claimed for pupils who do not meet those residency requirements and who are enrolled in the school district, county office of education, or charter school pursuant to the bills authorization for a pupil who is not fully immunized to enroll in an independent study program that is outside of the geographic boundaries of the pupils school district or county of residence.

Existing law states that it is the intent of the Legislature, with respect to direct service contracts of the departments within the California Health and Human Services Agency, that the contract approval process and payment for services rendered occur within specified timeframes.

This bill would make technical, nonsubstantive changes to those provisions.

Date of Hearing: April 10, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2668

Author:(Travis Allen) – As Amended Ver:April 2, 2018

SUBJECT: Pupil immunizations: pupils not immunized.

SUMMARY: Eliminates private institutions, including private elementary and secondary schools, child care centers, day nurseries, nursery schools, family day care homes, and development centers from the requirement that children receive immunizations for specified diseases prior to being admitted to any public or private elementary or secondary school, or day care center. Specifically, this bill:

1. Permits a pupil who does not meet immunization requirements to enroll in an independent study program that does not require classroom-based instruction and that is outside of the geographic boundaries of the school district or county in which the pupil resides if the school district or county office of education of residence, or a charter school within the geographic boundaries of the school district or county of residence, does not offer an independent study program that does not require classroom-based instruction.
2. Permits a school district, county office of education, or charter school to claim independent study average daily attendance for a pupil who does not meet residency requirements of the district but is enrolled in the school district, county office of education, or charter school pursuant to 1) above.
3. Permits the parent or guardian of a child who would otherwise be eligible to attend a public elementary or secondary school, child care center, day nursery, nursery school, family day care home, or development center, except for the child not meeting immunization requirements to apply to the California Department of Education (CDE) for a grant to fund the child’s attendance at a private elementary or secondary school, child care center, day nursery, nursery school, family day care home, or development center, as applicable.
4. Requires CDE to determine the amount it would cost the state for a child of each applicable age level to attend a public elementary or secondary school, child care center, day nursery, nursery school, family day care home, or development center, and requires CDE to set that amount as the grant amount for a child of that age level to attend a private elementary or secondary school, child care center, day nursery, nursery school, family day care home, or development center.
5. Requires CDE to award a grant to a parent or guardian that applies for the specified grant in 3) above and that demonstrates that his or her child does not meet immunization requirements.
6. Requires a continuous appropriation for the amount required to award grants from the General Fund to CDE to r parents and guardians that qualify for the grants.

EXISTING LAW:

1. Prohibits the governing authority of a school or other institution from unconditionally admitting any person as a pupil of any private or public elementary or secondary school, child care center, day nursery, nursery school, family day care home, or development center, unless, prior to his or her first admission to that institution, he or she has been fully immunized against diphtheria, pertussis (whooping cough), and tetanus [DTP]; measles, mumps, and rubella (German measles) [MMR]; Haemophilus influenzae type b (Hib meningitis); poliomyelitis (polio); hepatitis B; and, varicella (chickenpox).
2. 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 Committee on Infectious Diseases.
3. Exempts pupils in a home-based private school or enrolled in an independent study program and does not receive classroom-based instruction from the immunization requirements in 1) above.
4. Exempts pupils from the immunization requirements in 1) above if the parent, guardian, or an emancipated minor, filed a letter prior to January 1, 2016, with the governing authority stating that the immunization is contrary to his or her beliefs (personal belief exemption or PBE) until the pupil enrolls in the next grade span.
5. Specifies that a pupil who qualifies for an individualized education program is not prohibited from accessing any special education and related services required by his or her individualized education program.

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

COMMENTS:

1. PURPOSE OF THE BILL. The author states that while it is the state’s prerogative to provide mandates to public schools, it is the parents' right as taxpayers to have options available to them as well. SB 277 (Pan), Chapter 35, Statutes of 2015, went as far as mandating that charter and private schools must abide by this policy as well, leaving parents virtually nowhere to go if they have concerns with vaccines. According to the author, the U.S. government has an entire division set up to compensate families for vaccine injuries with more than $82.9 million paid out as of February 1, 2018 for vaccine damages. Since 1988, over 18,426 petitions have been filed with the National Vaccine Injury Compensation Program (NVICP). Over that 29-year time period, 16,555 petitions have been adjudicated, with 5,581 of those determined to be compensable, while 10,974 were dismissed. Keep in mind the CDC estimates that only about 10% of adverse events are reported. Total compensation paid over the life of the program is approximately $3.7 billion. While vaccines have revolutionized the way society looks at health, they like all things are not without their unintended side effects. No medical intervention is completely risk free. The author concludes that vaccines, though they are designed to protect from disease, can cause side effects that cannot be denied and range from mild to serious. Where there is risk there must be choice.
   
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. Vaccine helped to eradicate smallpox, one of the most devastating diseases in history. Over the years, vaccines have prevented countless cases of infectious diseases and saved literally millions of lives.
   
   Vaccine-preventable diseases have a costly impact, resulting in doctor's visits, hospitalizations, and premature deaths. Sick children can also cause parents to lose time from work. CDC sets the childhood immunization schedule based on recommendations from ACIP. TheACIP is comprised of 15 experts that collaborate and work closely with professional organizations such as American Academy of Pediatrics and the American Academy of Family Physicians. The ACIP rigorously examine research and stay up to date on the latest information regarding vaccine safety. The ACIP examine the safety and effectiveness of vaccines when given at specific ages, the severity of the disease being prevents, the number of children who get the disease if there is no vaccine, and how well a vaccine works for children of different ages.
   
   In the U.S., the high vaccination rate for routinely recommended immunizations for infant and childhood diseases has brought about dramatic declines in the incidence of polio, measles, mumps, rubella, Haemophilus influenza type b, hepatitis, and chickenpox. In the past decade, recommendations for annual influenza vaccination have been expanded to encompass all children six months to 18 years of age, and new vaccines have been added to the immunization schedule to help protect infants from rotavirus disease and adolescents from meningitis. As a result of the advances in developing vaccines and including them as standard of care, most diseases that are preventable by vaccination are at record low levels in the U.S.
   
   In the past couple of decades, controversy has arisen about vaccines and autism, the best number of injections to be administered during a single visit or over the course of the first years of life, and vaccine ingredients which has prompted parents, the media, policy makers, and others to raise concerns about the safety of recommended immunizations as well as the vaccination schedule. Despite their positive impact on health and well-being, vaccines have had a long history of inciting anxiety. The Internet and social media are avenues in which it is easy to find, but also spread inaccurate information regarding immunizations.
   
   In 2014, the measles outbreak linked to Disneyland is a prime example of how a small population of unvaccinated children can cause an outbreak. It was reported that in 2013, 92.3% of California’s kindergartners received the measles vaccination. Experts state that if the vaccination rate for measles falls below 95% conditions become favorable for potential measles outbreaks. The following year, in 2014, a measles outbreak struck at Disneyland and became California’s worst measles outbreak since 1991, ultimately infecting more than 150 people and crossed into other states. This illustrates that through decreasing the number of children to become vaccinated, even by a small percentage, this can have serious and harmful impacts that even goes beyond state lines.
   
   The more individuals who are vaccinated, the fewer opportunities a disease has to spread. By eliminating the necessity for certain populations to receive vaccinations has grave implications for our current community, but also impacts the following generations. Diseases that we have seen almost eliminated could easily return and result in an epidemic that could take decades to control. History has shown, like the case in Disneyland, disease outbreaks can easily spread when we exempt even a small population from the necessary vaccinations.
3. School IMMUNIZATION requirements. States have enacted laws or regulations that require children to receive certain vaccines before they enter childcare facilities and school, but with some exceptions, including medical, religious, and philosophical objections. School vaccination requirements are thought to serve an important public health function, but can also face resistance.
   
   An article published in the 2001-02 Kentucky Law Journal reviewed historical and modern legal, political, philosophical, and social struggles surrounding vaccination requirements. The authors of the article stated that though school vaccination has been an important component of public health practice for decades, it has had a controversial history in the U.S. and abroad. Historical and modern examples of the real, perceived, and potential harms of vaccination, governmental abuses underlying its widespread practice and strongly held religious beliefs have led to fervent objections among parents and other persons who object to vaccines on legal, ethical, social, and epidemiological grounds. The article states that public health authorities argue that school vaccination requirements have led to a drastic decrease in the incidence of once common childhood diseases. Those who object to vaccines tend to view the consequences of mass vaccination on an individualistic basis, focusing on alleged or actual harms to children from vaccinations. As part of their research, the authors compared childhood immunization rates and rates of vaccine-preventable childhood diseases before and after the introduction of school vaccination requirements. The data suggest that school vaccination requirements have succeeded in increasing vaccination rates and reducing the incidence of childhood disease.
   
   Current state law mandates immunization of school-aged children against 10 specific diseases. Each of the 10 diseases was added to California code through legislative action, after careful consideration of the public health risks of these diseases, cost to the state and health system, communicability, and rates of transmission. The following is a brief summary of activity related to mandated immunizations for children enrolling in school:

1889: School districts first allowed to exclude a student who is not vaccinated against smallpox, and schools were required to maintain a list of unvaccinated children (SB 92 (Briceland), Chapter 24, Statutes of 1889).

1961: Polio immunization added as a requirement, as well as the first appearance of a philosophical exemption (AB 1940 (DeLotto and Rumford), Chapter 837, Statutes of 1961).

1977: Diphtheria, pertussis, tetanus, and measles were added to immunization requirements for children entering school (SB 942 (Rains), Chapter 1176, Statutes of 1977). 

1979: Mumps and rubella were added to the list (AB 805 (Mangers), Chapter 435, Statutes of 1979). 

1992: Haemophilus influenzae type b was added (AB 2798 (Floyd), Chapter 1300, Statutes of 1992 and AB 2294 (Alpert), Chapter  1320, Statutes of 1992). 

1995 and 1997: Hepatitis B was added (AB 1194 (Takasugi), Chapter 291, Statutes of 1995 and AB 381 (Takasugi), Chapter 882, Statutes of 1997).

1999: The Legislature voted to add Hepatitis A to the list, but it was vetoed by Governor Davis (AB 1594 (Florez)).

1999: Varicella was added to the list (SB 741 (Alpert), Chapter 747, Statutes of 1999). 

2007: The Legislature voted to add pneumococcus to the list, but it was vetoed by Governor Schwarzenegger (SB 533 (Yee)).

2010: Tetanus, diphtheria, and pertussis (TDaP) booster was required for 7^th graders (AB 354 (Arambula), Chapter 434, Statutes of 2010).

All of the diseases for which California requires school vaccinations are very serious conditions that pose very real health risks to children. Most of the diseases can be spread by contact with other infected children. Tetanus does not spread from student to student but because it is such a serious potentially fatal disease, and it is easily preventable by vaccine, the vaccination of children is required prior to enrollment in school.

1. COMMUNITY IMMUNITY. Herd immunity occurs when a significant proportion of the population (or the herd) has been vaccinated, and this provides protection for unprotected individuals. The larger the number of people who are 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 immunity of their community.
   
   There the protective effect of herd immunity wanes as large numbers of children do not receive some or all of the required vaccinations, resulting in the reemergence of vaccine preventable diseases in the U.S. Statewide statistics indicate that in 2014-15 school year, 90.4% of kindergartens received all required immunizations. The widespread reporting of statewide numbers, however, potentially mask a better understanding of more relevant data, such as town, city, or county vaccination rates. Because students are not interacting with every individual in the entire state, the local vaccination rate is more relevant to the discussion of community immunity.
   
   The vaccination rate in various communities varies widely across the state. Those areas become more susceptible to an outbreak than the state’s overall vaccination levels may suggest. These communities make it difficult to control the spread of disease and make us vulnerable to having the virus re-establish itself.
   
   Studies find that when PBEs to vaccination guidelines are permitted, vaccination rates decrease. An analysis by the New York Times found that more than a quarter of schools in California have measles-immunization rates below the 92-94% recommended by the CDC. Research shows that people with lower vaccine acceptance tend to group together in communities. A study recently published in the journal Pediatrics found that schools with high PBE rates are clustered in suburbs in the peripheral areas of California cities. The same analysis found that schools with low proportion of white students, or a high proportion of students receiving free or reduced lunch, were more likely to have high vaccination rates (less PBEs).
   
   In 1974, Japan had a successful whooping cough vaccination program where roughly 80% of Japanese children were vaccinated and no deaths were reported due to whooping cough. However, shortly after rumors spread that the whooping cough vaccination may no longer be needed and that the vaccine itself has harmful resulting. As a result, in 1976 only 10% of Japanese infants were vaccinated and in 1979 and there was a 3,000% increase of whooping cases and 41 deaths. Vaccines are successful when entire populations are immunized. If only some individuals are vaccinated the virus or disease can spread rapidly because only some individuals have immunity. According to the CDC, if one or even two cases of disease are introduced into a community where most people are not vaccinated outbreaks will occur.
2. National Childhood Vaccine Injury Act. During the mid-1970s, there was an increased focus on personal health and more people became concerned about vaccine safety. Several lawsuits were filed against vaccine manufacturers and healthcare providers by people who believed they had been injured by the TDaP vaccine. Damages were awarded despite the lack of scientific evidence to support vaccine injury claims. In 1976, a preemptive attempt to conduct a nationwide influenza vaccination campaign for the swine flu stoked peoples' fears. The predicted epidemic did not occur and there were some who argued this particular influenza vaccine resulted in serious side effects.
   
   As a result, potential liability costs and vaccine prices soared, and several vaccine manufacturers halted production. A vaccine shortage resulted and public health officials became concerned about the return of epidemic disease.
   
   To reduce liability and respond to public health concerns, Congress passed the National Childhood Vaccine Injury Act (NCVIA) in 1986. The NCVIA established the National Vaccine Program Office to coordinate immunization related activities among various federal agencies and requires health care providers who give vaccines to provide an information statement to the patient or guardian that contains a brief description of the disease as well as the risks and benefits of the vaccine. Additionally, the NCVIA requires health care providers to report certain adverse health events following vaccination to the Vaccine Adverse Event Reporting System (VAERS). The VAERS system remains an important source of information for the CDC and others to monitor the vaccine program, but the system allows self-reporting by any citizen or healthcare provider what they believe to be an adverse vaccine-related event, but the event numbers publicly available have not necessarily been medically verified or scientifically studied. The National Vaccine Injury Compensation Program (NVICP) was created to compensate those injured by vaccines on a "no fault" basis. The NVICP has been loudly criticized by some for inefficient operations, and for providing legal immunity to the pharmaceutical industry.
   
   The NCVIA established a committee from the Institute of Medicine (IOM) to review the literature on vaccine reactions. This group concluded that there are limitations in our knowledge of the risks associated with vaccines. The group looked at 76 health problems to see if they were caused by vaccines. Of those, 50 (66%) had no or inadequate research to form a conclusion. The IOM identified several specific problems, such as a limited understanding of biological processes that underlie adverse events, incomplete and inconsistent information from individual reports, poorly constructed research studies (not enough people enrolled for the period of time), inadequate systems to track vaccine side effects, and few experimental studies were published in the medical literature. The CDC states that in the time since the publication of the IOM reports in the 1990s, significant progress has been made to monitor side effects and conduct research relevant to vaccine safety. In 2011 the IOM published Adverse Effects of Vaccines: Evidence and Causality, representing an extensive study of peer-reviewed vaccine related research to date. The IOM Committee reviewed eight vaccines given to children or adults (MMR, varicella, influenza, hepatitis A, hepatitis B, human papillomavirus, meningococcal, and DTP) and again found that vaccines are generally very safe and that serious adverse events are quite rare.
3. SPECIAL EDUCATION. Pursuant to the federal Individuals with Disabilities Education Act (IDEA), children with disabilities are guaranteed the right to a free, appropriate public education, including necessary services for a child to benefit from his or her education. Between 1976 and 1984, to meet this federal mandate, California schools provided mental health services to special education students who needed the services pursuant to an Individualized Education Program (IEP). An IEP is a legally binding document that determines what special education services a child will receive and why. IEPs include a child's classification, placement, specialized services, academic and behavioral goals, a behavior plan if needed, percentage of time in regular education, and progress reports from teachers and therapists. A child may require any related services in order to benefit from special education, including (but not limited to): speech-language pathology and audiology services, early identification and assessment of disabilities in children, medical services, physical and occupational therapy, orientation and mobility services; and psychological services. According to CDE, over 750,000, or approximately 11% of, California students received Special Education services in the 2016-17 academic year.
4. Independent Study. This bill permits a pupil who does not meet immunization requirements to enroll in an independent study program that does not require classroom-based instruction and that is outside of the geographic boundaries of the school district or county in which the pupil resides, as specified. Independent study is an optional educational alternative, available to students from kindergarten through high school that is meant to respond to the student's specific educational needs, interests, aptitudes, and abilities. Independent study is an alternative to classroom instruction consistent with a school district's regular course of study and is expected to be equal or superior in quality to classroom instruction. Each school district can develop Independent Study options in its own way. Parents and students may also develop alternative forms of independent study and propose them to the school board. The options are based on the kinds of students being served. The following are some of the ways in which independent study is organized:
   1. School-within-a-school;
   2. District or county alternative in a community location;
   3. School-based independent study offered part-time and full-time;
   4. Countywide home-based independent study offered by the county superintendent of schools;
   5. District dropout prevention centers at selected community sites;
   6. Curricular enrichment options offered to high school students with special abilities and interests, scheduling problems, or individual needs that cannot be met in the regular program;
   7. Alternative school-based independent study, on-or off-site; and,
   8. Some combination of the above.

Independent study can be operated on a traditional school calendar, with a summer school option for eligible students, or on a year-round calendar within a year-round school. Students must have the option of a classroom setting for a full program at the time independent study is made available. This option must be continuously available the student decide to transfer from independent study. The classroom setting option can be offered by the county office of education if the district and county have a formal agreement that has the effect of providing the student with a program that is equivalent to what is offered in the school of residence.

Participation in independent study must be voluntary. For students participating in independent study, a contractual agreement is drawn among the certificated teacher, the student, and his or her parent, guardian, or caregiver. Attendance records are based on a student’s work within the terms and conditions of his or her written agreement and not on traditional “seat-time.” In independent study, the student’s performance, measured by the terms in the agreement, is converted by the supervising teacher into school days. The computed school days are reported as if the student were physically in attendance. According to CDE, in 2014-15 there were approximately 168,000 independent study students reported by charter schools and school districts.

1. PREVIOUS LEGISLATION.
   1. SB 277 (Pan), Chapter 35, Statutes of 2015, eliminated non-medical exemptions from the requirement that children receive vaccines for certain infectious diseases prior to being admitted to any public or private elementary or secondary school, or day care center.
   2. AB 2109 requires, on and after January 1, 2014, a separate form prescribed by DPH to accompany a letter or affidavit to exempt a child from immunization requirements under existing law on the basis that an immunization is contrary to beliefs of the child's parent or guardian. Required the form to include:
      1. A signed attestation from the health care practitioner that indicates that the parent or guardian of the person who is subject to the immunization requirements, the adult who has assumed responsibility for the care and custody of the person, or the person if an emancipated minor, was provided with information regarding the benefits and risks of the immunization and the health risks of the communicable diseases listed above to the person and to the community; and,
      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 i) above.
      3. The Governor included a message with his signature on this bill, which stated, in part:
      4. “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.”
   3. SB 614 (Kehoe), Chapter 123, Statutes of 2011, allows a pupil in grades seven through 12, to conditionally attend school for up to 30 calendar days beyond the pupil's first day of attendance, if that pupil has not been fully immunized with all pertussis boosters appropriate for the pupil's age if specified conditions are met.
   4. AB 354 allowed DPH to update vaccination requirements for children entering schools and child care facilities and added the American Academy of Family Physicians to the list of entities whose recommendations DPH must consider when updating the list of required vaccinations. Requires children entering grades seven through 12 to receive a TDaP booster prior to admittance to school.
   5. 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 the Senate Health Committee.
2. POLICY COMMENT. There is no data to suggest this bill is necessary.

REGISTERED SUPPORT / OPPOSITION:

Support

None on file.

Opposition

None on file.

Analysis Prepared by: Paula Villescaz & Monica Montano / HEALTH / (916) 319-2097