Big story: mandatory vaccinations?

08 March 2018

Measles has been surging across Europe amid high levels of safety-based vaccine scepticism and falling immunisation levels. Italy and France have responded with new laws that make childhood vaccinations mandatory. Journalist Juliette Astrup takes a look at this controversial issue and asks what should be done to keep uptake rates high.

accination programmes are one of the most effective public health interventions in the world for saving lives and promoting good health (PHE, 2016). Diseases that previous generations feared, such as smallpox, have been consigned to history, and polio has almost been completely eradicated.

But producing and supplying an effective vaccination is not enough. Uptake must be high, with the WHO recommending a 95% coverage rate for herd immunity.

Under-vaccination has one inevitable result – outbreaks of disease, as seen with measles following the decline in the rate of measles, mumps and rubella (MMR) vaccinations.


Measles outbreak

Suboptimal vaccine coverage has caused the spread of measles across much of Europe, according to a European Centre for Disease Prevention and Control (ECDC) report.

From 1 January 2016 to 30 June 2017, more than 14,000 measles cases and 34 related deaths were recorded. Most, 37%, were in Italy (ECDC, 2017), where the number of two-year-olds vaccinated against measles has dropped from more than 90% to below 80% (BBC, 2017). Romania accounted for 35% of the total, Germany 9% and the UK 5% (ECDC, 2017). The UK had another measles outbreak this winter.

While vaccination uptake across the UK remains high, it is also true that in some areas it has been falling, or failing to meet the requisite 95% (NHS Digital, 2017).

The reasons for this are complex, but widely understood to be down in part to the complacency that arises when successful vaccinations erase the threat of once-feared diseases from the public consciousness.

Fears around the safety of vaccines have also had an impact, particularly following health scares, such as the long-discredited paper by Andrew Wakefield that claimed a link between the MMR vaccine and autism.

More recently, campaigners dubbed the ‘anti-vax’ movement have used social media to discourage others from immunising by citing supposed risks.

According to a vaccine confidence study of 67 countries, vaccine-safety sentiment is particularly negative in Europe. Seven of the 10 least confident countries are European, with 41% of respondents in France saying they disagree that vaccines are safe, compared with a global average of 13% (Larson et al, 2016).


New laws

Both France and Italy have high levels of safety-based vaccine scepticism (Larson et al, 2016), and are still considered to have endemic transmission of measles (ECDC, 2017). They have also announced new vaccine mandates.

Italy enacted new laws last year to make vaccination for 10 diseases mandatory for children aged between one and 16 years. The laws prohibit unvaccinated children from attending kindergartens, and children must be vaccinated before starting primary school or their parents will incur heavy fines (Ministero della Salute, 2018). France’s new mandatory 11-vaccine course, up from three previously, came into effect from 1 January 2018 (Ministère des Solidarités et de la Santé, 2017).

Australia has gone even further with its so-called ‘no jab-no play’ policy which bans unvaccinated children from enrolling in pre-school and childcare centres. Under the ‘no jab-no pay’ law, parents of unvaccinated children lose government benefits and welfare rebates (The Lancet Infectious Diseases, 2017).

Inevitably such decisions are highly controversial, seen as encroaching on freedom and a child’s right to education. Such laws have sparked protests wherever they have been introduced.

The idea of compulsory vaccinations has been debated in the UK too. After a measles outbreak across Wales in 2009 led to 253 cases of the disease, health minister Edwina Hart announced she was prepared to ‘explore further’ the options for a compulsory childhood vaccination policy for Wales (BBC, 2009).

The subject was also raised at the British Medical Association (BMA) annual representative meeting last year, where a motion called on the organisation to look at the advantages and disadvantages of making childhood immunisation mandatory (Forster, 2017). A spokesperson says the BMA has not changed its stance, and added that the organisation is calling for ‘increasing efforts to improve awareness of the benefits of vaccination, particularly among parents’ as well as ‘sufficient funding to deliver fully resourced vaccination services’.


Enforcing comprehensive coverage

Even where immunisation is compulsory, universal coverage is not guaranteed. In the US, where it has long been the case that children are required under state law to be vaccinated against certain communicable diseases before they can go to school and day care (Centers for Disease Control and Prevention, 2017), non-medical vaccine exemptions – on religious or philosophical grounds – are on the rise.

The clustering of vaccine refusal has created hot spots where herd immunity against vaccine-preventable disease is compromised. For example, the number of pertussis (whooping cough) cases in 2012 was the highest since 1955, a significant jump that has been linked with this rise in non-medical exemptions (Aloe et al, 2017).

The UK approach

The UK has ultimately preferred non-punitive measures to keep vaccination rates high across the four nations.

In Scotland, where uptake rates for the majority of childhood immunisations sit at around 95%, a government spokesman says there is ‘no justification to make childhood immunisations mandatory under law’.

Similarly, in Northern Ireland, where coverage levels have historically been the highest in the UK, the question of making immunisations compulsory does not arise and the focus remains firmly on well-trained healthcare staff.

Dr Lucy Jessop, a health protection consultant at the Northern Ireland Public Health Agency, says: ‘I think you need well-trained and well-informed staff on the ground who are able to answer parents’ questions, and that helps increase parental confidence.’

A Welsh Government spokesperson agrees: ‘When it comes to immunising our children, efforts should focus on providing parents with reassurance and information based on sound scientific evidence and medical advice.

‘We believe that compulsory vaccination would adversely affect the trust most parents have in local health professionals.’

However, in England, childhood immunisation uptake rates are often lower. In 2016-17, four of the six routine vaccinations at one and two years showed small decreases in coverage compared with the previous year. This included the MMR vaccine, at two years, which was down for the third year in a row to 91.6% (NHS Digital, 2017).

There is no immediate cause for alarm as overall vaccine coverage rates remain high, says David Green, nurse consultant for immunisations at Public Health England. While he concedes that the ‘absolute reasons’ for the gradual decline in uptake (‘between 0.5% and 1% over the last four years’) aren’t entirely clear, it is not thought to be down to vaccine hesitancy.

‘We don’t think that vaccination hesitancy is a major issue. Most parents, about 90%, automatically book appointments for their newborns to receive routine core immunisations,’ he says. ‘And we don’t think the anti-vax movement is having an impact, certainly from our own research in terms of vaccination attitudes.’


Confidence in vaccination

Recent research found that confidence in and acceptance of the vaccination programme in England was high, with only 2% of parents refusing vaccination, and 90% saying they vaccinated their children automatically when due.

Of respondents, 90% agreed or strongly agreed that health professionals and the NHS are the most trusted source of advice on immunisation (Campbell et al, 2017).

The authors conclude: ‘Health professionals remain extremely important in communicating information about vaccination and are highly trusted by parents; a trust that has increased in recent years.

‘Despite most parents seeking information on the internet, trust in and advice from healthcare professionals appeared to be key factors influencing parental decisions.’

David Green agrees it is vital that healthcare professionals who work with children must promote vaccinations. ‘In general, parental confidence is high, but it is also important that they address any parental concerns,’ he adds.

And mandatory vaccines are ‘not something we are considering at the moment’, he says. ‘It’s about parent choice, and the vast majority of parents choose rightly to have their child immunised. We see our focus as facilitating that choice.’

As vaccination policies outside the UK show, removing choice does not guarantee high rates of immunisation, and education and engagement can be more successful in winning hearts and minds. 


Aloe C, Kulldorff M, Bloom BR. (2017) Geospatial analysis of nonmedical vaccine exemptions and pertussis outbreaks in the United States. Proceedings of the National Academy of Sciences. See: www.pnas.org/content/early/2017/06/19/1700240114.full (accessed 20 February 2018).

BBC. (2009) MMR school entry check considered. See news.bbc.co.uk/1/hi/wales/8079770.stm (accessed 12 February 2018)

BBC. (2017) Italy makes 12 vaccinations compulsory for children. See: www.bbc.co.uk/news/world-europe-39983799 (accessed 12 February 2018).

Campbell H, Edwards A, Letley L, Bedford H, Ramsay M, Yarwood J. (2017) Changing attitudes to childhood immunisation in English parents. Vaccine 35(22): 2979-85. See: www.ncbi.nlm.nih.gov/pubmed/28442229 (accessed 20 February 2018).

Centers for Disease Control and Prevention. (2017) State school immunization requirements and vaccine exemption laws. See: www.cdc.gov/phlp/docs/school-vaccinations.pdf (accessed 20 February 2018).

European Centre for Disease Prevention and Control. (2017) Bi-annual measles and rubella monitoring report. See: https://ecdc.europa.eu/sites/portal/files/documents/Bi-annual%20measles%20rubella%20monitoring-OCT-2017.pdf (accessed 20 February 2018).

Larson H, de Figueiredo A, Xiahong Z, Schulz WS, Verger P, Johnston IG, Cook AR, Jones NS. (2016) The state of vaccine confidence 2016: global insights through a 67-country survey. EBioMedicine 12: 295–301. See: www.ncbi.nlm.nih.gov/pmc/articles/PMC5078590 (accessed 20 February 2018).

Ministère des Solidarités et de la Santé. (2017) 11 vaccins obligatoires en 2018. See: solidarites-sante.gouv.fr/prevention-en-sante/preserver-sa-sante/vaccination/vaccins-obligatoires/article/11-vaccins-obligatoires-en-2018 (accessed 20 February 2018).

Ministero della Salute. (2018) Vaccinazioni. See: http://www.salute.gov.it/portale/vaccinazioni/homeVaccinazioni.jsp (accessed 20 February 2018).

NHS Digital. (2017) Childhood vaccination coverage statistics, England, 2016-17. See: digital.nhs.uk/catalogue/PUB30085 (accessed 20 February 2018).

Public Health England. (2016) Health matters: giving every child the best start in life. See: www.gov.uk/government/publications/health-matters-giving-every-child-the-best-start-in-life/health-matters-giving-every-child-the-best-start-in-life (accessed 20 February 2018).

Forster K. (2017) Doctor blames Andrew Wakefield and antivaxxers for her baby son catching measles. The Independent. See: www.independent.co.uk/news/health/doctor-blames-andrew-wakefield-son-catching-measles-vaccine-mmr-autism-anti-vaxxers-measles-a7813001.html (accessed 20 February 2018).

The Lancet Infectious Diseases. (2017) The imperative of vaccination. The Lancet Infectious Diseases 17(11): 1099. See: www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30590-X/fulltext (accessed 20 February 2018).

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