Should the UK introduce compulsory vaccination?

The political economy of digital profiteering: communication resource mobilization by anti-vaccination actors

Contemporary communication requires both a supply of content and a digital information infrastructure. Modern campaigns of misinformation are especially dependent on that back-end infrastructure for tracking and targeting a sympathetic audience and generating revenue that can sustain the campaign financially-if not enable profiteering. However, little is known about the political economy of misinformation, particularly those campaigns spreading misleading or harmful content about public health guidelines and vaccination programs. To understand the political economy of health misinformation, we analyze the content and infrastructure networks of 59 groups involved in communicating misinformation about vaccination programs. With a unique collection of tracker and communication infrastructure data, we demonstrate how the political economy of misinformation depends on platform monetization infrastructures. We offer a theory of communication resource mobilization that advances understanding of the communicative context, organizational interactions, and political outcomes of misinformation production.

Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates

BACKGROUND

Vaccine hesitancy is a global problem with diverse local policy responses, from voluntaristic to coercive. Between 2015 and 2017, California, Australia, France, and Italy increased the coerciveness of their childhood vaccine regimes. Despite this apparent convergence, there is little evidence of imposition, policy learning, or diffusion - the drivers that are usually discussed in scholarly literature on policy convergence. The fact that the four governments were oriented across the political spectrum, with quite different political and institutional systems, further indicates an empirical puzzle.

METHODS

To better understand the drivers of enhanced vaccine mandates, a crucial issue during the coronavirus disease 2019 (COVID-19) global rollout, this article engages with four case studies assembled from qualitative analysis of semi-structured in-country interviews and document analysis between November 2018 and November 2020. Key informants had specific expert knowledge or played a role in the introduction or implementation of the new policies. Interview transcripts were coded inductively and deductively, augmented with extensive analysis of legal, policy, academic and media documents.

RESULTS

The case analysis identifies two key and interacting elements in government decisions to tighten vaccine mandates: functional and political pressures. Policy-makers in Italy and France were primarily driven by functional challenges, with their vaccination governance systems under threat from reduced population compliance. California and Australia did not face systemic threats to the functioning of their systems, but activists utilised local opportunities to heighten political pressure on decision makers.

CONCLUSION

In four recent cases of high-income jurisdictions making childhood vaccination policies more coercive, vaccine hesitancy alone could not explain why the policies arose in these jurisdictions and not others, while path dependency alone could not explain why some jurisdictions with mandates made them more coercive. Explanation lies in restrictive mandates being attractive for governments, whether they face systemic functional problems in vaccine governance, or political pressures generated by media and activists. Mandates can be framed as targeting whole populations or localised groups of refusers, and implemented without onerous costs or policy complexity.

Parental preferences for a mandatory vaccination scheme in England: A discrete choice experiment

Background

Mandatory vaccination has been mooted to combat falling childhood vaccine uptake rates in England. This study investigated parental preferences for a mandatory vaccination scheme.

Methods

Discrete choice experiment. Six attributes were investigated: vaccine, child age group, incentive, penalty, ability to opt out, and compensation scheme. Mixed effects conditional logit regression models were used to investigate parental preferences and relative importance of attributes.

Findings

Participants were 1,001 parents of children aged 5 years and under in England (53% female; mean age=33·6 years, SD=7·1; 84% white). Parental preferences were mostly based on incentives (30·7% relative importance; 80·9% [95% confidence interval 76·3–85·0%] preference for parent and 74·8% [71·0–78·3%] for child incentive; reference: no incentive) and penalties (25·4% relative importance; 69·5% [65·7–73·1%] preference for schemes where unvaccinated children cannot attend school or day care and 67·6% [63·6–71·4%] for those withholding financial benefits for parents of unvaccinated children; reference: £450 fine). Parents also preferred schemes that: offered a compensation scheme (18·1% relative importance; 66·4% [62·7–69·8%] preference; reference: not offered), mandated vaccination in children aged 2 years (versus 5 years; 11·4% relative importance; 42·6% [39·4–45·9%] preference; reference: 2 years), mandated the 6-in-1 vaccine (10·5% relative importance; 58·2% [54·6–61·7%] preference; reference: MMR), and that offered only medical exemptions (versus medical and religious belief exemptions; 4·0% relative importance; 45·5% [41·1–50·0%] preference; reference: medical exemptions).

Interpretation

These findings can inform policymakers’ decisions about how best to implement a mandatory childhood vaccination scheme in England.

Funding

Data collection was funded by a British Academy/Leverhulme Small Research Grants (SRG1920\101118).

Current understandings of the impact of mandatory vaccination laws in Europe

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.

Inaction, under-reaction action and incapacity: communication breakdown in Italy's vaccination governance

This article explores why governments do not respond to public compliance problems in a timely manner with appropriate instruments, and the consequences of their failure to do so. Utilising a case study of Italian vaccination policy, the article considers counterfactuals and the challenges of governing health policy in an age of disinformation. It counterposes two methods of governing vaccination compliance: discipline, which uses public institutions to inculcate the population with favourable attitudes and practices, and modulation, which uses access to public institutions as a form of control. The Italian government ineffectively employed discipline for a number of years. Epistemological and organisational constraints stymied its efforts to tackle a significant childhood vaccination compliance problem. With a loss of control over the information environment, vaccinations were not served well by exogenous crises, the sensationalism of the news cycle and online misinformation. Hampered by austerity, lack of capacity and epistemic shortcomings, the Italian government did not protect the public legitimacy of the vaccination programme. Instead of employing communications to reassure a hesitant population, they focused on systemic and delivery issues, until it was too late to do anything except make vaccinations mandatory (using modulation). The apparent short-term success of this measure in generating population compliance does not foreclose the need for ongoing governance of vaccine confidence through effective discipline. This is evident for the COVID-19 vaccination campaign, with many Italians still indicating that they would not accept a vaccine despite the devastation that the disease has wrought throughout their country.

The Dizziness of Freedom: Understanding and Responding to Vaccine Anxieties

The rise in vaccine hesitancy in high-income countries has led some to recommend that certain vaccinations be made compulsory in states where they are currently voluntary. In contrast, I contend that legal coercion is generally inappropriate to address the complex social and psychological phenomenon of vaccine anxieties.

Mandatory vaccination for infants and children: the Italian experience

Maintaining high vaccination coverage is important in order to protect the individual and the community. Mandatory vaccination is an option in case of declining coverage. Widely used in the USA, it is considered a rather controversial issue in Europe. In Italy, after a decrease of vaccination coverage for the hexavalent and the MPR vaccine under the optimal threshold, a new law, which extended the number of mandatory vaccines from 4 to 10 and reinforced coercive measures, was introduced in July 2017. After 2 years, vaccination coverage increased for all mandatory vaccines and for the other two recommended vaccines (anti-pneumococcal and anti-meningococcal C). Although it is not possible to disentangle the role of other factors contributing to the positive outcome, consistently with the results of studies conducted in the USA, vaccine mandates appeared to be successful in increasing vaccination coverage in Italy. The long-term sustainability of the effect of mandatory vaccination and the potential negative drawbacks of the coercive measures need to be evaluated to generate scientific evidence in public health.

Would it be legally justified to impose vaccination in Israel? Examining the issue in light of the 2013 detection of polio in Israeli sewage

Background

The detection of wild poliovirus in Israeli sewage in May 2013 led the health authorities to decide that children who had been vaccinated with IPV would also be vaccinated with OPV. The decision sought to protect vulnerable Israeli individuals who were either not vaccinated with IPV or who suffered from an immune deficiency, to preserve Israel’s status as a polio-free country, to prevent the virus’ “exportation” into vulnerable polio-free countries, and to participate in the global efforts toward the eradication of polio. After a massive public persuasion campaign, 79% of the children born after 2004 were vaccinated as well as 69% of the children residing in central Israel. A 2014 State Comptroller Report stated that the Ministry of Health should draw conclusions from the low compliance rates in certain Israeli regions.

Goals

The article seeks to examine the legal legitimacy of mandatory vaccination in the service of eradicating a contagious disease (as opposed to preventing a pandemic outbreak), which was one of the objectives in the 2013 Polio case. It more specifically relates to current Israeli law as well as to a hypothetical new public health law which would authorize health officials to oblige vaccination and enforce this through the use of criminal sanctions.

Method

Qualitative content analysis through the interpretation of court judgements, laws, legislative protocols, health ministry guidelines and documented discussions of the Advisory Committee on Infectious Diseases and Immunization.

Main findings and conclusion

A mandatory vaccination backed by criminal sanctions in the service of the eradication of contagious diseases would probably be perceived as infringing on the constitutional right to autonomy to a greater extent than necessary according to Israeli law and case law precedents. There may be some added value inherent in a new public health law which would authorize health officials to oblige vaccination where nonrestrictive measures have been ineffective. However, the law should also specify a variety of sanctions to accompany the enforcement of mandatory vaccinations which would be formulated from least to most restrictive according to the “intervention ladder” concept. The law should also describe the circumstances which would justify the implementation of each and every sanction as well as the procedural safeguards designed for established decisions and fairness toward the individual(s) whose rights are infringed by the application of these sanctions.

Are we ready to abrogate compulsory vaccinations for children?

In Italy, vaccination against diphtheria, tetanus, polio and hepatitis B is compulsory for infants countrywide, except in Veneto region where since 2007 Health Authorities have experimented the suspension of mandatory vaccination. In light of the recent discussion on the potential abrogation in other regions, we explored the opinion of family pediatricians who play a crucial role in promoting immunization programmes in Italy. In November 2009, we interviewed by phone the family pediatricians working in Puglia region using a standardised, ad hoc and piloted questionnaire. Of the 596 contacted, 502 (84.2%) completed the questionnaire (54% female, median age = 52 y). Among the respondents, 72 (14.3%) would agree on the hypothesis of abrogation. This judgment was associated with having a good opinion on the level of awareness of the importance of vaccinations in the general public (OR = 6.6; 95% CI: 3.6-12.1) and having the perception of adequate organization of Vaccination Services in supporting the abrogation (OR = 3.6; 95% CI: 1.7-5.9). Family pediatricians appeared really sceptical about the abrogation of compulsory vaccination that could be hypothesized only increasing public awareness, communication skills and capability of Vaccination Services personnel in offering vaccinations.