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.

Provide Vaccines, Not Require Immunity or Vaccination Passports … For Now

In principle, mandatory vaccination in employment could be justified in certain circumstances. These include: (1) the availability of safe and effective vaccination; (2) if alternative, less coercive strategies did not work; and, (3) the costs to the individual were proportionate. However, in COVID-19, the long term safety of vaccines is yet to be established. Vaccines should be made available by employers, and voluntary vaccination encouraged.

Health literacy, emotionality, scientific evidence: Elements of an effective communication in public health

The importance of healthcare providers' communication abilities is still underestimated. Informing the population on the basis of documented evidence is essential but not enough to induce a change in the beliefs of who is doubtful or does not accept preventive interventions, such as vaccination. Lining up the offer of prevention to the knowledge of the citizens, also improving Health Literacy skills, is a critical step toward their empowerment and behavior change. The 2017 Erice Declaration was drafted to propose to the Institutions and the scientific community the main goals to improve communication and counteract Vaccine Hesitancy, at a very critical time, when mandatory vaccination was introduced in Italy.

Outcomes, Approaches, and Challenges to Developing and Passing a Countywide Mandatory Vaccination Policy: St. Louis County's Experience with Hepatitis A Vaccine for Food Service Personnel

In the early 1990s, St. Louis County had multiple foodservice worker-related hepatitis A outbreaks uncontrolled by standard outbreak interventions. Restaurant interest groups and the general public applied political pressure to local public health officials for more stringent interventions, including a mandatory vaccination policy. Local health departments can enact mandatory vaccination policies, but this has rarely been done. The study objectives were to describe the approach used to pass a mandatory vaccination policy at the local jurisdiction level and illustrate the outcome from this ordinance 15 years later. A case study design was used. In-depth, semi-structured interviews using guided questions were conducted in spring, 2015, with six key informants who had direct knowledge of the mandatory vaccination policy process. Meeting minutes and/or reports were also analyzed. A Poisson distribution analysis was used to calculate the rate of outbreaks before and after mandatory vaccination policy implementation. The policy appears to have reduced the number of hepatitis A outbreaks, lowering the morbidity and economic burden in St. Louis County. The lessons learned by local public health officials in passing a mandatory hepatitis A vaccination policy are important and relevant in today's environment. The experience and lessons learned may assist other local health departments when faced with the potential need for mandatory policies for any vaccine preventable disease.