Current understandings of the impact of mandatory vaccination laws in Europe

ABSTRACT

Vaccinations are among the most successful preventive tools to protect collective health. In response to alarming vaccines preventable diseases (VPDs) outbreaks resurgence, decreased vaccination coverage and vaccine refusal, several European countries have recently revised their vaccination policies introducing or extending mandatory vaccinations. This review examines the health, political and ethical aspects of mandatory vaccination.

The authors first clarify terms and definitions and propose a conceptual framework of mandatory policies. Second, they describe the current status of mandatory childhood immunization programmes in Europe, assessing selected mandatory laws. Third, as the authors conduct a systematic review of the literature (retrieving from Medline 17 relevant records between 2010 and 2020), they take an analytical approach to measure the impact of mandatory vaccination policies on both VPDs control and immunization coverage, but also on population attitudes toward vaccines. 40% of European countries currently have mandatory vaccination policies; however, policies vary widely and, although there is evidence of increased vaccine uptake, their impact on informed adherence to preventive behaviors is scant.

Although mandatory vaccination policies might be needed to protect collective health in times of emergency, public health goals of VPD prevention and health promotion should primarily be pursued through health education and population empowerment.

KEYWORDS:

• Europe
• immunization
• mandatory vaccination
• policies impact
• review

Article highlights

• National health authorities have a mandate to protect public health. The Constitutions of several countries in the EU explicitly guarantee citizens’ right to public health. Immunization is one of the most successful preventive tools to protect individual and collective health;

• The EU political and technical bodies have repeatedly called for strengthened cooperation towards VPD control in the context of a resurgence in disease outbreaks, reduced vaccination coverage and hesitancy in some settings.

• Several countries have revised their vaccination policies, introducing or extending mandatory requirements where individuals are legally required to be vaccinated, or have their children vaccinated. The spectrum of mandatory vaccination policies is wide, ranging from flexible to more punitive approaches.

• There is an ongoing debate around the health, ethical and policy rationale of mandatory vaccination for children, healthcare workers as well as other target populations. We propose a comprehensive theoretical conceptual framework of mandatory immunization policies.

• 40% of EU/EEA countries currently have mandatory vaccination policies in place, including Italy, France and Germany which passed new laws on mandatory vaccination, respectively in, 2017, 2018 and 2020. They are however highly heterogeneous in their requirements, sanctions and penalties.

• Different observational study designs can be applied to assess the impact of mandatory vaccination policies, including analytical pre-post, ecological and difference in difference studies, all having strengths and weaknesses.

• Overall, there is evidence that mandatory vaccination increases vaccine uptake over time in children, adolescents and healthcare workers; however, impacts on rates vary by setting and immunization programmes. Scant and inconclusive evidence is available on the impact of mandatory vaccination policies on norms’ acceptance and attitudes towards vaccinations;

• Mandatory immunization is a paternalistic approach to public health protection which might be considered to increase vaccine uptake and limit the risk caused by VPDs outbreaks in emergency times; however, more flexible approaches should be envisaged. Ultimately, public health goals of VPDs prevention and health promotion are to be pursued first through convenient and high-quality services, health education and population empowerment.

Author contributions

Giulia Dallagiacoma and Beatrice Frascella contributed equally

Declaration of interest

The authors report no conflicts of interest

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Supplementary material

Supplemental data for this article can be accessed here.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.