Mandatory vaccination: does it work in Europe?

Gary Finnegan

Gary Finnegan

November 27th, 2017

Gary Finnegan
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‘As Europe battles measles outbreaks, Italy, Romania, France and Finland are tightening their vaccination laws. The benefits are questionable. ’

Compulsory vaccination was first introduced in the UK – where no vaccines are currently mandated – through the 1853 Vaccination Act. The law required that all children ‘whose health permits’ be vaccinated against smallpox, and obliged physicians to certify that vaccination had taken place. Parents who refused vaccination could be fined £1.

Since then, vaccine mandates have evolved to include a variety of incentives and penalties. In some US states, children cannot access public schools without being vaccinated; in Australia, compliance with childhood immunisation schedules has been linked to pre-school admission (‘No jab, no play’) and to family assistance payments (‘No jab, no pay’).

In most instances where vaccine mandates are in force, they apply only to childhood immunisation. However, vaccination is a condition of employment in some institutions – notably in healthcare facilities. This is not a legal mandate per se but is a form of discrimination accepted in several jurisdictions. In principle, mandates – like vaccines – can be for people of all ages.

The state of play in Europe

In Europe, the picture is mixed. A 2010 study of 27 EU countries (plus Iceland and Norway) found that 15 had no mandatory vaccines. In the meantime, Italy has added 10 vaccines to its list of compulsory vaccines; France and Romania are preparing new laws that would penalise parents of unvaccinated children; and Finland will introduce legislation in March 2018 that requires health and social care providers to ensure staff are immunised against measles, varicella, pertussis and influenza. The diversity of measures taken suggests no proven strategy exists that can be universally applied. 

So, why is there a trend towards mandates and other legal instruments? Political science research on the value of international sanctions against rogue nations has found that while they are often ineffective, sanctions may give some satisfaction to the government implementing the rules. The same may apply to vaccine mandates. ‘Sanctions are often more about the sender than the recipient,’ says Dr Katie Attwell, University of Western Australia, ‘Maybe it’s more of an emotional experience for those who want to punish a country – or, in in the case of vaccinations, a citizen – that deviates from the norm.’

The impact of mandates in European countries has been assessed by the EU-funded ASSET project which found no clear link between vaccine uptake and mandatory vaccination. The report, which has been cited by the European Commission in response to questions from Members of the European Parliament states: ‘The enforcement of mandatory vaccinations does not appear to be relevant in determining childhood immunisation rate in the analysed countries. Those [countries] where a vaccination is mandatory do not usually reach better coverage than neighbour or similar countries where there is no legal obligation.’

ASSET experts have also argued that while mandatory vaccination might fix a short-term problem, it is not a long-term solution. Better organisation of health systems and strong communication strategies may prove more effective. ‘Mandatory vaccinations for both healthcare workers and the public can obtain a rapid improvement in immunisation rates, but in the end, have high costs, especially in term of litigation,’ says Dr Darina O’Flanagan, previous Director of Health Protection Surveillance Centre Ireland and a member of the Advisory Forum of the European Centre for Disease Control 2005-2016.

This is echoed by the EU Commissioner with responsibility for health, Dr Vytenis Andriukaitis ‘The legitimate goal of achieving the highest possible immunisation rates can be attained through less stringent policies, and most Member States prefer the adoption of ‘recommendation policies’ or else a mix of obligation/recommendation policies,’ according to EU Commissioner.

In the meantime, Italy – and by 2018, France and Romania – will be a real-world testbed for the implementation of broad vaccine mandates in the 21st century. Prof Pierluigi Lopalco, University of Pisa, says mandates may polarise public opinion. ‘Consider the Three Cs (Confidence, Complacency and Convenience),’ he says. ‘Mandates do not improve vaccine confidence; they make opposition to vaccination even stronger. However, they are a powerful way to break complacency and this new approach should make vaccination services more convenient and efficient.’

Conclusion

There is no one-size fits all approach to improving vaccine uptake. Some countries with mandates, such as Poland, have high vaccination rates; others, such as Finland, achieve similar results without mandates.

The real power of a mandate is not in coercing reluctant parents to vaccinate children against their will; it is in sending a signal to the wider population that vaccination is a vital part of public health. In this sense, the momentum generated by the debate on mandatory vaccination may have some positive effect. The risk, however, is that it will spark an anti-vaccine backlash equal to – or greater than – this positive signal. This risk would be amplified in cases where vaccine supply or access to vaccination services is not guaranteed, as has been the case in Romania.

A more promising move would be to invest in understanding the behavioural drivers of vaccine acceptance. Including this issue in the forthcoming EU Action Plan on Vaccination, due to be launched in 2018, would be a welcome initiative. In the meantime, it is essential that legislative changes be closely monitored in Italy, Romania, France and Finland – along with policy measures in Germany and other countries where mandates are not in place.

There may not be a silver bullet for vaccine hesitancy but research and sharing experiences are Europe’s best hope for controlling vaccine-preventable diseases.

Comments

  1. Pingback

    Pingback

    December 4th, 2017

    […] As flu season gets underway, the UK’s National Health Service advised that child ‘super spreaders’ must be vaccinated in order to protect elderly relatives, and a review in NEJM discussed the need for a universal influenza vaccine. There were also calls for children to receive the measles, mumps and rubella vaccine following reports of cases in two UK cities. Meanwhile, Vaccines Today asked ‘does mandatory vaccination work in Europe?’ […]

  2. truth

    truth

    March 21st, 2018

    You won’t succeed in imposing mandatory vaccinations in Poland. No way it’ s gonna happen. We know it’s a global agenda

    • bercello

      bercello

      June 7th, 2018

      We did succeeded. There are mandatory vaccinations in Poland. It happened and is happening. It is global agenda, like humanity, logic and common sense.

      • Mac

        Mac

        September 21st, 2018

        No, it is gross abuse of power by the state.

        Vaccination is not a straight forward matter, and there are thousands of children round the world who have been severely damaged by vaccines.

        Compulsory vaccination is medication by force. Do similar to an adult, and you would be in court.

      • Mariusz Sochacki

        Mariusz Sochacki

        October 6th, 2018

        Some vaccinations are compulsory for children in Poland. Not for adults. But it looks like even this regulation is going to be repealed in October 2018. Legislation project is already in parliament.

        • Magdalena Ferenc

          Magdalena Ferenc

          November 9th, 2018

          Some? Are you kidding? Most of them are compulsory.

  3. Jean

    Jean

    July 6th, 2018

    I don’t understand why some vaccines are mandatory. Like Hepb at birth! HepB is transmitted like AIDS is transmitted. Blood, used needles or sexually. I don’t see newborns having these issues. By the time the child is nearing the sexually active stage in life, a booster is needed because the original vaccine only lasts about 10 years. I think we are over doing things and it could just be the reason you see so many Americans with autoimmune diseases. I can see the need for such vaccines like Polio or measles but it’s gotten out of hand in my opinion.

  4. Mariusz Sochacki

    Mariusz Sochacki

    October 6th, 2018

    Compulsory vaccinations are nothing more than infringement on freedom of choice. Everyone has a right to decide if wan’t something done to their body or not. IF vaccinations are so critical then educate people and convince them that they should take them by presenting relevant research on how they help and what are the risks. No government has a right to decide for its citizens nor force them to do anything they don’t feel like doing. History teaches us that every service/product sharply drops in quality right after people no longer have choice if they gonna use it or not.

    • Alec

      Alec

      November 2nd, 2018

      While vaccines do affect our rights, not getting them affects everyone around us. For instance, if you did not get the measles vaccine, and contract the measles, you may recover fine. However, while contagious you could have exposed a child too young to be vaccinated or a immunodeficient one to the disease. The fatally rate for immunodeficient people is up to 70%. Addressing your other point about gov’ts forcing people to do things they don’t want to do, that’s kinda the government’s job. Do you pay taxes? As for your last point, can you link some sources about products quality dropping?