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. Sunny

    Sunny

    March 19th, 2020

    Hi Gary,

    It took me a while to research the above 2 links about long-term double-blind placebo studies. I admit I am again missing a satisfactory pro-vaccination explanation for the lack of double-blind placebo safety testing of vaccines.
    The 2 studies above do make sense. But they apply only to the demand from anti-vaxxers for a *long-term* double-blind placebo study of the *entire vaccine schedule*. But then that is not the concern that is being brought up by many anti-vaxxers . (May be there are some anti-vaxxers who demand that. And the links above do a good job of responding to that demand).
    But if we look at clinical trials of any individual vaccine on the schedule, there is almost none that have been tested against a placebo. The usual pro-vax answer to that is “that would be unethical because it would jeopardize the subject receiving the saline placebo. So instead of a placebo we use another vaccine with a known safety profile which itself was tested against a placebo or itself was tested with a control that was in turn tested against a saline placebo”.
    But that is not turning out to be true.
    If you try to trace back any vaccine on the current schedule and find out which control was used during the clinical trial and then in turn look at the original clinical trial of that control, you still don’t end up with a vaccine that was tested against a placebo.
    In one case, Gardasil was tested against an aluminium compound, which is not even a vaccine —- and I am yet to find an explanation why)
    Is my information accurate?

  2. Andokz

    Andokz

    March 28th, 2020

    Anyone seeing the connection between Italy’s mandatory vaccinations and corona virus

    • Gary Finnegan

      Gary Finnegan

      March 30th, 2020

      No.
      Please share your theory and any supporting evidence you may have.
      If not, perhaps you could hold your conspiracy theories and avoid capitalising on the misery that people in Italy, Spain and the rest of the world are suffering.

      • Erik

        Erik

        April 2nd, 2020

        No brain washer , I dont want that vaccine , already had you disease and beat it !

        • Gary Finnegan

          Gary Finnegan

          April 2nd, 2020

          Well done, Erik. If you ‘beat’ coronavirus that’s great for you. Meanwhile, tens of thousands of people are dead and millions more are at risk. But it’s good that you’re alright and won’t be in the long queue for a vaccine next year.

    • Bob Miuller

      Bob Miuller

      May 17th, 2020

      No, actually I sure don’t. I don’t even see how it has anything to do with the title of the story.

  3. Silver

    Silver

    April 10th, 2020

    @David and a chew

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