Current understandings of the impact of mandatory vaccination laws in Europe

Impact of Australia's No Jab, No Pay policy on vaccination uptake - a before-after study in two national birth cohorts

Background

Data on impact of financial penalties for non-vaccination are sparse. Australia has required full vaccination for government family assistance payment eligibility since 1998. In 2016, the No Jab, No Pay (NJNP) policy removed registered non-medical objection as exemption option and increased eligibility assessment to yearly. We aimed to examine NJNP impact on vaccine uptake in children.

Methods

Individual-level Australian Immunisation Register data were used to assemble two-year-wide pre-/post-NJNP birth cohorts aged 1-<3 years, stratified by registered objection (yes/no) and vaccination status (zero-dose/partially vaccinated/fully vaccinated). At 5-<7 years, we measured odds ratios (ORs) and 95% confidence interval (CIs) for vaccination outcomes post-versus pre-NJNP and compared observed post-NJNP numbers with those expected if proportions pre-NJNP applied.

Findings

Pre-NJNP of 562,316 children aged 1-<3 years, 92.1% were fully vaccinated, 4.9% partially vaccinated and 3.0% zero-dose; objection was registered for 1.1% overall (23.9% of zero-dose). Post-NJNP of 615,607 aged 1-<3 years, 92.7% were fully vaccinated, 4.7% partially vaccinated, 2.6% zero-dose; objection was registered for 1.5% overall (37.7% of zero-dose). By 5-<7 years of age, full vaccination was significantly higher post-than pre-NJNP in children with registered objection (zero-dose 14.6% versus 1.2% [OR 14.1; 95% CI 10.5-18.9]; partially vaccinated 41.7% versus 8.4% [OR 7.9; 95% CI 6.4-9.7]) and without objection (zero-dose 10.1% versus 4.9% [OR 2.2; 95% CI 2.0-2.4]; partially vaccinated 39.2% versus 34.5% [OR 1.2; 95% CI 1.1-1.3]). Post-NJNP we estimated 49,510 more children (3.7% with registered objection) to be fully vaccinated than expected. Odds of remaining zero-dose were 0.38 (95% CI 0.34-0.42) with versus 0.66 (0.63-0.70) without registered objection and fewer children (9,206, 1.5%) were persistently zero-dose post-than pre-NJNP (10,696, 1.9%).

Interpretation

Full vaccination by age 5-<7 years increased post-NJNP irrespective of baseline vaccination/objection status. Relative increases were much higher among children with registered objection than without, but partially vaccinated children without objection largely accounted for numerical increases, suggesting increased eligibility assessment was more important than changes in exemption criteria.

Funding

Australian Government Department of Health and Aged Care.

Childhood Mandatory Vaccinations: Current Situation in European Countries and Changes Occurred from 2014 to 2024

Background/Objectives: Vaccination is one of the most effective public health interventions, preventing millions of deaths globally each year. However, vaccine hesitancy, driven by misinformation and reduced disease risk perception, has led to declining vaccination rates and the resurgence of vaccine-preventable diseases (VPDs) in Europe. In response to this, countries have implemented various strategies, including mandatory and recommended vaccination programs. The objective of this study is to map the current European landscape of pediatric vaccination policies, and the variations that have occurred in the last decade. Methods: This rapid review was conducted on PubMed, Google, and the European Centre for Disease Prevention and Control website, to collect all vaccination schedules in EU/EEA countries in 2024 and all documents focusing on the introduction of mandatory vaccines during the last decade. Results: As of 2024, 13 countries had at least one mandatory pediatric vaccination, with France, Hungary, and Latvia requiring all but one vaccine. In contrast, 17 countries had no mandatory vaccinations, relying only on recommendations. Between 2014 and 2024, six countries (Croatia, France, Germany, Hungary, Italy, and Poland) introduced or extended mandatory vaccinations. Conclusions: European vaccination policies show significant variation. Effective programs depend on robust healthcare systems, public trust, and adaptable strategies to address vaccine hesitancy and the resurgence of VPDs.

Decision Regret and Vaccine Hesitancy among Nursing Students and Registered Nurses in Italy: Insights from Structural Equation Modeling

This study focused on vaccine hesitancy and decision regret about the COVID-19 vaccine among nursing students (BScN and MScN) and Registered Nurses (RNs) in Italy. The primary aim was to describe decision regret and vaccine hesitancy among these groups and to understand what influences vaccine hesitancy. Data were collected through an e-survey conducted from March to June 2024. The Decision Regret Scale and the Adult Vaccine Hesitancy Scale were employed to assess regret and hesitancy levels, assessing trust, concerns, and compliance regarding vaccination. Among the participants, 8.64% were not vaccinated. The results indicated moderate to high levels of decision regret and diverse levels of trust, concerns, and compliance with COVID-19 vaccination. Structural equation modeling revealed that decision regret significantly predicted Trust (R2 = 31.3%) and Concerns (R2 = 26.9%), with lower regret associated with higher trust and lower concerns about vaccine safety. The number of COVID-19 vaccine boosters was a significant predictor of Trust and Concerns, with more boosters associated with higher trust and lower concerns. MScN students exhibited higher Compliance compared to RNs (R2 = 2.9%), highlighting the role of advanced education. These findings suggest that addressing decision regret and providing comprehensive vaccine information could enhance trust and compliance.

Understanding Factors Contributing to Vaccine Hesitancy in a Large Metropolitan Area

Vaccine hesitancy has become a major global concern, leading to a significant decrease in the vaccination rate, with the World Health Organization recognizing it as one of the top ten threats to public health. Moreover, the health cost generated is evaluated to be 27 billion dollars per year in the US alone. To investigate the association between demographic variables and knowledge, attitudes, and behaviours related to vaccination, a survey-based cross-sectional study was conducted with 1163 individuals. Three models were used to perform a multiple linear regression analysis. In Model I, knowledge about vaccinations was found to be associated with smoking habits, education, and marital status. In Model II, attitudes towards vaccinations were significantly associated with sex, smoking habits, education, marital status, and knowledge. In Model III, behaviours related to vaccination were associated with sex, smoking habits, having children, knowledge, and attitudes. One potential solution to improve behaviours related to vaccinations in the general population is to implement specific public health programs, which can be a cost-effective intervention. This study provides valuable insights into the determinants of knowledge, attitudes, and behaviours related to vaccinations in the general population.

Healthcare professionals' attitudes to mandatory COVID-19 vaccination: Cross-sectional survey data from four European countries

Mandatory vaccinations are widely debated since they restrict individuals' autonomy in their health decisions. As healthcare professionals (HCPs) are a common target group of vaccine mandates, and also form a link between vaccination policies and the public, understanding their attitudes toward vaccine mandates is important. The present study investigated physicians' attitudes to COVID-19 vaccine mandates in four European countries: Finland, France, Germany, and Portugal. An electronic survey assessing attitudes to COVID-19 vaccine mandates and general vaccination attitudes (e.g. perceived vaccine safety, trust in health authorities, and openness to patients) was sent to physicians in the spring of 2022. A total of 2796 physicians responded. Across all countries, 78% of the physicians were in favor of COVID-19 vaccine mandates for HCPs, 49% favored COVID-19 vaccine mandates for the public, and 67% endorsed COVID-19 health passes. Notable differences were observed between countries, with attitudes to mandates found to be more positive in countries where the mandate, or similar mandates, were in effect. The associations between attitudes to mandates and general vaccination attitudes were mostly small to neglectable and differed between countries. Nevertheless, physicians with more positive mandate attitudes perceived vaccines as more beneficial (in Finland and France) and had greater trust in medical authorities (in France and Germany). The present study contributes to the body of research within social and behavioral sciences that support evidence-based vaccination policymaking.

Vaccine Mandates in the COVID-19 Era: Changing Paradigm or Public Health Opportunity? Comment on "Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates"

The debate around vaccine mandates has flourished over the last decade, with several countries introducing or extending mandatory childhood vaccinations. In a recent study, Attwell and Hannah explore how functional and political pressures added to public health threats in selected countries, motivating governments to increase the coerciveness of their childhood vaccine regimes. In this commentary, we reflect on whether such model applies to the coronavirus disease 2019 (COVID-19) case and how the pandemic has re-shuffled the deck around vaccine mandates. We identify COVID-19 immunisation policies' distinctive aspects as we make the case of countries implementing mass immunisation programmes while relying on digital COVID-19 certificates as an indirect form of mandate to increase vaccine uptake. We conclude by acknowledging that different forms of mandatory vaccination might serve as a shortcut to protect population health in times of emergency, underlining, however, that the ultimate public health goal is to promote voluntary, informed, and responsible adherence to preventive behaviours.

Evolving measles status and immunization policy development in six European countries

Developing and implementing new immunization policies in response to shifting epidemiology is a critical public health component. We adopted a mixed-methods approach (via narrative literature review [101 articles] and 9 semi-structured interviews) to evaluate policy development in response to shifting measles epidemiology in six European countries (Italy, Belgium, Germany, Romania, UK, and Ukraine); where policies and strategies have evolved in response to country-specific disease and vaccination patterns. Periodic outbreaks have occurred in all countries against a background of declining measles-containing-vaccine (MCV) uptake and increasing public vaccine hesitancy (with substantial regional or social differences in measles burden and vaccine uptake). Health-care worker (HCW) vaccine skepticism is also seen. While many outbreaks arise or involve specific susceptible populations (e.g., minority/migrant communities), the broader pattern is spread to the wider (and generally older) population; often among incompletely/non-vaccinated individuals as a legacy of previous low uptake. Immunization policy and strategic responses are influenced by political and social factors, where public mistrust contributes to vaccine hesitancy. A strong centralized immunization framework (allied with effective regional implementation and coherent political commitment) can effectively increase uptake. Mandatory vaccination has increased childhood MCV uptake in Italy, and similar benefits could be anticipated for other countries considering vaccine mandates. Although possible elsewhere, socio-political considerations render mandating impractical in other countries, where targeted immunization activities to bolster routine uptake are more important. Addressing HCW skepticism, knowledge gaps, improving access and increasing public/community engagement and education to address vaccine hesitancy/mistrust (especially in communities with specific unmet needs) is critical.

Delays in routine childhood vaccinations and their relationship with parental vaccine hesitancy: a cross-sectional study in Wuxi, China

OBJECTIVES

This study aimed to examine childhood vaccination delay, explore the association between vaccination delay and parental vaccine hesitancy, and assess childhood vaccination delays during the coronavirus disease (COVID)-19 pandemic in China.

METHODS

This cross-sectional survey was conducted in Wuxi City. Participants were recruited from local vaccination clinics. Questionnaires were used to collect information about socio-demographics, vaccine hesitancy, and immunization clinic evaluations. Vaccination records were obtained from the Jiangsu Information Management System of Vaccination Cases.

RESULTS

Overall, 2728 participants were included. The coverage for seven category A vaccines (Expanded Program on Immunization (EPI)) was more than 95% at 24 months. The proportion of children vaccinated in a timely manner was the highest for the first dose of the hepatitis B vaccine (91.6%) and the lowest for the Bacillus-Calmette-Guerin vaccine (44.6%). More than 50% of the planned vaccinations were delayed in February and March 2020. The Vaccine Hesitancy Scale scores were not associated with vaccination delay (P = 0.842). Children's vaccination delays were negatively associated with parents who reported convenient access to clinics and satisfaction with immunization services (P = 0.020, P = 0.045).

CONCLUSIONS

EPI is highly successful in China. Despite vaccination delays due to the COVID-19 pandemic, coverage was recovered after lockdown restrictions were eased.

Oxford COVID-19 Vaccine Hesitancy in School Principals: Impacts of Gender, Well-Being, and Coronavirus-Related Health Literacy

Purposes: To explore the associated factors of COVID-19 vaccine hesitancy and examine psychometric properties of the coronavirus-related health literacy questionnaire (HLS-COVID-Q22) and Oxford COVID-19 Vaccine Hesitancy questionnaire. Methods: An online survey was conducted from 23 June to 16 July 2021 on 387 school principals across Taiwan. Data collection included socio-demographic characteristics, information related to work, physical and mental health, COVID-19 related perceptions, sense of coherence, coronavirus-related health literacy, and vaccine hesitancy. Principal component analysis, correlation analysis, linear regression models were used for validating HLS-COVID-Q22, Oxford COVID-19 Vaccine Hesitancy, and examining the associations. Results: HLS-COVID-Q22 and Oxford COVID-19 Vaccine Hesitancy were found with satisfactory construct validity (items loaded on one component with factor loading values range 0.57 to 0.81, and 0.51 to 0.78), satisfactory convergent validity (item-scale correlations range 0.60 to 0.79, and 0.65 to 0.74), high internal consistency (Cronbach’s alpha = 0.96 and 0.90), and without floor or ceiling effects (percentages of possibly lowest score and highest score <15%), respectively. Low scores of vaccine hesitancy were found in male principals (regression coefficient, B, −0.69; 95% confidence interval, 95%CI, −1.29, −0.10; p = 0.023), principals with better well-being (B, −0.25; 95%CI, −0.47, −0.03; p = 0.029), and higher HLS-COVID-Q22 (B, −1.22; 95%CI, −1.89, −0.54; p < 0.001). Conclusions: HLS-COVID-Q22 and Oxford COVID-19 Vaccine Hesitancy were valid and reliable tools. Male principals and those with better well-being, and higher health literacy had a lower level of vaccine hesitancy. Improving principals’ health literacy and well-being is suggested to be a strategic approach to increase vaccine acceptance for themselves, their staff, and students.

Improved Temporal Trends of Vaccination Coverage Rates in Childhood after the Mandatory Vaccination Act, Italy 2014-2019

Maintaining high vaccine coverage (VC) for pediatric vaccinations is crucial to ensure herd immunity, reducing the risk of vaccine-preventable diseases (VPD). The Italian vaccination Law (n. 119/2017) reinforced mandates for polio, diphtheria, tetanus, and hepatitis B, extending the mandate to pertussis, Haemophilus influenzae type b, chickenpox, measles, mumps, and rubella, for children up to 16 years of age. We analyzed the national temporal trends of childhood immunization rates from 2014 to 2019 to evaluate the impact of the mandatory reinforcement law set in 2017 as a sustainable public health strategy in Italy. In a 3-year period, 9 of the 10 compulsory vaccinations reached the threshold of 95% and VC for chicken pox increased up to 90.5%, significantly. During the same period, the recommended vaccinations (against meningococcus B and C, pneumococcus, and rotavirus) also recorded a significant increase in VC trends. In conclusion, although the reinforcement of compulsory vaccination generated a wide public debate that was amplified by traditional and social media, the 3-year evaluation highlights positive results.

SARS-CoV-2 Vaccination in Children and Adolescents-A Joint Statement of the European Academy of Paediatrics and the European Confederation for Primary Care Paediatricians

Stopping the COVID-19 pandemic and its socio-economic consequences is only possible with a multifaceted strategy, including mass vaccination. Studies have been conducted mainly in adults, and data on the pediatric population is relatively limited. However, it appears that vaccination in children and adolescents is highly effective and safe. Despite the apparent benefits of vaccinating this age group, there are some medical and ethical concerns. Based on the above considerations, the European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Pediatricians (ECPCP) assessed the current situation and presented recommendations for international and national authorities, pediatricians, and pediatric societies regarding vaccination against SARS-CoV-2 in children and adolescents.