Mandatory Vaccination

by

Katie Attwell

• LAST REVIEWED: 25 August 2021
• LAST MODIFIED: 25 August 2021
• DOI: 10.1093/obo/9780199756797-0207

Introduction

Across the world, mass vaccination programs run by governments or third-sector organizations have saved countless lives; minimized human suffering; and maintained economic, social, and cultural functioning. Vaccination programs predominantly focus on diseases that once ravaged the infant and early childhood years. However, with significant global variation, vaccination programs also exist for adolescents, pregnant women, new parents, the elderly, and people with comorbidities as well as catch-up or booster programs for particular age groups or vaccines. Governments and organizations also run annual influenza vaccination programs for entire populations or key workers, and health-care and education workers may be subject to additional vaccination requirements. The commonality of all mass vaccination programs is that the state adopts a key role in planning, coordinating, and funding them, or implementing mechanisms to ensure vaccines’ receipt by populations. The state’s role makes mandatory vaccination a possibility. Numerous scholarship forms the evidence base for the safety, efficacy, and necessity of vaccines. However, vaccination as a practice has consistently been accompanied by a minority who doubt and refuse, either for some or all vaccines. Concern about refusal has grown in recent years. An extensive Oxford Bibliographies article, “Vaccine Hesitancy,” explains why doubt and refusal develop and persist, how scholars make sense of it, and how governments and health-care providers can address it. However, hesitancy is not the only determinant of suboptimal vaccine uptake. Vaccination programs can also fail to reach populations due to insufficient generation of demand, inefficient or inappropriate service provision, cost barriers, and access barriers. Understanding the determinants of undervaccination in any given region, country, or population group will be essential to determining what strategies, including mandatory vaccination, are appropriate. Mandatory vaccination is just one strategy among a suite of tools that governments and organizations can employ to increase uptake of vaccines by particular cohorts. Mandatory vaccination is receiving current attention due to governments in several high-income jurisdictions recently utilizing it to address parents’ vaccine hesitancy. However, as the scholarship in this article illuminates, many jurisdictions’ mandatory childhood vaccination policies predate current concerns around hesitancy. Mandates have long performed key roles in the governance of vaccination uptake, including in contexts where attention to other programmatic aspects or health promotion practices may be lacking. The author would like to acknowledge the assistance of Amy Morris in the writing of the Mandatory Vaccination of Health-Care Workers—Policies, Experiences, and Impact and the Mandatory Vaccination—Attitudinal Studies sections of this article.

General Overviews

The current global interest in mandatory vaccination starts with the urgent need to determine what mandatory means from a policy instrument and behavioral perspective, given the recent rise in adoption of such policies. Older studies, such as Lantos, et al. 2010, and more recent works, such as Walkinshaw 2011, attempt to define the field and to categorize vaccine mandates across multiple jurisdictions. Attwell, et al. 2018; MacDonald, et al. 2018; and Attwell and Navin 2019 seek to make sense of mandates’ growing adoption and enhancement. Scholars often attempt to understand the practical and ethical implications of mandates as a tool to address vaccine hesitancy or suboptimal uptake as well as to generate best practice recommendations, as seen in Omer, et al. 2019. Explanatory and contextual work in Paul and Loer 2019 and McCoy 2019 situate mandatory vaccination policies within comparative studies to demonstrate that “mandatory” and “voluntary” are not simple, binary categories, and that mandatory policies are likely to evolve from existing governance conditions, strategies, and instruments. There are several important features of mandatory policies that impact their operation and—more importantly—their power to make people vaccinate, or what Attwell and Navin 2019 call their “salience.” The authors’ conceptual and theoretical work—along with an earlier iteration in Attwell, et al. 2018 and a complementary framework developed in MacDonald, et al. 2018—draw out mandates’ key features. To talk about mandatory vaccination policies, we need to understand the populations to which they apply; the vaccines involved, the nature and extent of incentives or punishments for noncompliance; the legal or regulatory basis for the mandate; the inclusion of institutions such as schools, hospitals, or private businesses in the governance of vaccine mandates; the general conduct of enforcement; and how exemptions are structured (what type) and awarded (how easily). Different combinations of all these factors can give rise to mandatory vaccination regimes that are either extremely “hard,” “rigid,” or “restrictive” in terms of making people vaccinate, or are “soft,” “flexible,” or “permissive” in facilitating choice regarding vaccination, particularly by permitting formal refusal. Exemptions for refusers form a crucial component of US vaccination policies, as Opel, et al. 2017 elaborates. The terminology applied here labels “restrictive” mandates as those with only medical exemptions and “permissive” mandates allowing for personal belief or religious exemptions.

• Attwell, K., and M. C. Navin. 2019. Childhood vaccination mandates: Scope, sanctions, severity, selectivity, and salience. Milbank Quarterly 97.4: 978–1014.

  DOI: 10.1111/1468-0009.12417

  Attwell and Navin formally analyze which features of a mandate matter to its salience, or power to make someone vaccinate. Which vaccines are included, types of punishments, their severity, frequency, and enforcement, and the structure of exemptions are systematically explained. The authors conclude that these factors mean vaccine mandates must be assessed in context and comparatively, rather than as abstract policy types.

• Attwell, K., M. C. Navin, P. Lopalco, C. Jestin, S. Reiter, and S. B. Omer. 2018. Recent vaccine mandates in the United States, Europe and Australia: A comparative study. Vaccine 19.36: 7377–7384.

  DOI: 10.1016/j.vaccine.2018.10.019

  This article takes as its starting point recent vaccine mandate developments in Australia, France, Germany, Italy, California, and the State of Washington. It describes the changes, their impetus, and constructs a continuum of coercion that considers punishments and exemptions. It considers both permissive and restrictive mandates but notes a general move toward restrictiveness. It also describes variable consequences including school exclusion, kindergarten and daycare exclusion, fines, and removal of government financial assistance.

• Lantos, J. D., M. A. Jackson, D. J. Opel, E. K. Marcuse, A. L. Myers, and B. L. Connelly. 2010. Controversies in vaccine mandates. Current Problems in Pediatric and Adolescent Health Care 40.3: 38–58.

  DOI: 10.1016/j.cppeds.2010.01.003

  This US-focused collection is a bit dated, but its strength lies in being a series of essays that considers mandates historically, and in childhood, teenage, and health-care worker populations. Not all sections are directly relevant to mandates. Inclusion of the process for adding new vaccines to a mandatory system is welcome.

• MacDonald, N. E., S. Harmon, E. Dube, et al. 2018. Mandatory infant & childhood immunization: Rationales, issues and knowledge gaps. Vaccine 36.9: 5811–5818.

  DOI: 10.1016/j.vaccine.2018.08.042

  This review article takes recent global developments as its starting point, and unpacks the factors comprising an approach to mandatory vaccination. The authors identify vaccine inclusion, age groups, program flexibility, and whether a vaccine injury compensation scheme is present as important factors. They offer a table with policy examples from high-, middle-, and low-income countries, and consider scenarios like pilgrims to Saudi Arabia needing meningococcal vaccine.

• McCoy, C. A. 2019. Adapting coercion: How three industrialized nations manufacture vaccination compliance. Journal of Health Politics, Policy and Law 44.6: 823–854.

  DOI: 10.1215/03616878-7785775

  This article is useful in identifying that mandatory and voluntary policies do not fall into a neat binary. McCoy attributes varying degrees of coercion in his deep, historical case studies of Britain, United States, and Australia to path-dependency and adaptive coercion in response to local resistance to vaccination programs. He considers how mandates work on both “passive” and “active” resistance.

• Omer, S. B., C. Betsch, and J. Leask. 2019. Mandate vaccination with care. Nature 571.7766: 469.

  DOI: 10.1038/d41586-019-02232-0

  This high-profile commentary draws on the authors’ global expertise in vaccination policies and programs, urging governments to approach mandates cautiously. Mandates may successfully lift rates in high income countries, but risk amplifying inequalities, especially in poorer countries. Analyzing global examples, the authors argue that optimum mandatory policy allows nonmedical exemptions but makes them difficult to access, and that mandates should join a suite of nonmandatory interventions to enhance coverage.

• Opel, D., J. Schwartz, S. B. Omer, et al. 2017. Achieving an optimal childhood vaccine policy. Jama Pediatrics 171.9: 893–896.

  DOI: 10.1001/jamapediatrics.2017.1868

  This article provides a useful overview of the historic centrality of nonmedical exemptions to childhood mandates in the United States. State-level school entry mandates are ubiquitous there, but only three states (in 2017) do not allow avenues to formally avoid them. The article then describes how the state of California and prominent medical associations are beginning to pivot away from permitting or supporting nonmedical exemptions, and considers the implications of their removal.

• Paul, K. T., and K. Loer. 2019. Contemporary vaccination policy in the European Union: Tensions and dilemmas. Journal of Public Health Policy.

  DOI: 10.1057/s41271-019-00163-8

  This perspective piece argues that recent attention on mandatory policies misses the diversity between policies and elides the “culturally contingent” local understandings of “mandatory” and “voluntary.” The authors’ Western European case studies pay attention to political principles, institutional structure, funding, guiding principles regarding vaccination, and policy instruments. They also look at the structure of the country’s National Immunization Policy and draw attention to important features such as monitoring.

• Walkinshaw, E. 2011. Mandatory vaccinations: The international landscape. Canadian Medical Association Journal 183.16: e1167–e1168.

  DOI: 10.1503/cmaj.109-3993

  Walkinshaw’s journalistic examination of the state of mandatory vaccination is dated and Canadian oriented. However, the article covers policies in a range of jurisdictions and considers the issues that they can raise. This article connects to two others in the same series, which explore the Canadian landscape and divergent viewpoints on whether mandatory vaccination policies are desirable or feasible. Marie-Claude Grégoire from the journal revisited the topic in 2019.