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Charting mandatory childhood vaccination policies worldwide [1]

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Date: 2021-07-05

Vaccines greatly reduce the burden of infectious disease. Despite their benefits, many people do not get themselves, or their children vaccinated. There are many reasons for low vaccine coverage, including not just vaccine refusal, but also practical issues such as access and availability. The problem with low uptake of vaccines is that relatively high levels of vaccine coverage – of up to 95% for example with measles are required to reach herd immunity – where the transmission of diseases is reduced and vulnerable individuals in the population protected [19].

One of the methods by which countries may try to achieve high levels of vaccine uptake is through mandatory vaccination policies, typically applied to childhood vaccination. Mandatory vaccination is becoming an increasingly important policy intervention for governments trying to address low vaccination rates. Although the term ‘mandatory’ and mandates are taken to mean quite different things across countries. Mandates require vaccination for a certain purpose, most commonly related to school entry for children. However, when it comes to overviews of country-specific vaccination practices and their impact, the information available about mandatory policy has largely been limited to high-income countries—particularly within Europe, the United States (US), Canada and Australia. While many recent publications discuss the issue of mandatory vaccination [17], [44], none provide a comprehensive and updatable database that includes low- and middle-income countries (LMICs). Such an overview would facilitate more informative comparisons between countries, to help governments make informed decisions about whether to introduce mandatory vaccination. This review presents a list of mandatory vaccination policies worldwide and inclusive of low- and middle-income countries, covering 149 countries worldwide. The list indicates whether a country has a mandatory vaccination policy and the strictness of the mandate on a scale ranging across four levels: Recommended, Mandatory, Mandatory for School Entry, and No Source (See Appendix. 1 for detail on characteristics of levels).

Several health institutions have been concerned with cataloguing mandatory vaccination policies. The World Health Organization (WHO) provides an ‘International travel and health’ country list of vaccination requirements for international travellers [77]. The European Centre for Disease Prevention and Control (ECDC) has established a network dedicated to vaccine-preventable diseases to collect, share and disseminate information on national vaccination programmes in EU/EEA Member States [18]. An earlier European-wide network called VENICE (Vaccine European New Integrated Collaboration Effort) established with support from the ECDC, conducted a 2010 survey on mandatory and recommended vaccination in the EU, Iceland and Norway [25]. Most recently, the Sabin Vaccine Institute published a review of vaccination policies for all 53 countries in the European region [56].

In addition, a number of academic articles have researched the relative merits of mandatory vaccination policies (e.g. [36], [5], [35], [67]). The most comprehensive recent academic articles [4], [23] list 62 countries with mandatory policies and 105 respectively. Whilst the Attwell et al. [5] lists several non-European countries, the focus of the paper has been on no-fault vaccine injury compensation schemes rather than creating a comprehensive database of mandatory policies. The Gravagna et al. [23] aims for a more comprehensive list but with a concentration on penalties as a consequence of non-compliance. Our paper builds on these findings by adding a number of other countries and discussing regional variation according to WHO regions [80]. To supplement this material, we consulted with experts from various health authorities. Overall, before our list, there has been a lack of openly available, up-to-date information about mandatory vaccination that does not focus primarily on European countries, the US, Canada, and Australia.

The paper is a review of the current state of play and provides an overview of the status of mandatory childhood vaccination across countries and regions, sets out the general trends and issues, and engages with a discussion about why, how, and where mandatory vaccination is put in place. For most countries worldwide, the responsibility lies with the government to provide access to vaccination (often at low or no cost), largely aimed at babies and children, through national immunisation schedules; along with individual responsibilities for parents to ensure their children are vaccinated. Therefore, we concentrate our analysis on paediatric immunisation. We are also mindful of the difference between the law or official policy, and what happens in practice—in terms of whether vaccination laws are followed and enforced, and whether alternatives exist to bypass the law. For example, if a country with mandatory vaccination for public school entry allows students to be home-schooled or privately schooled without requiring vaccination, this can offer an alternative for parents. The difference between law, policy, and practice will be discussed further in the paper.

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[1] Url: https://www.sciencedirect.com/science/article/pii/S0264410X21005478

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