An editorial in Eurosurveillance: Mandatory vaccination: suited to enhance vaccination coverage in Europe? Excerpt:
Vaccines are one of the most successful medical measures that save millions of human lives every year. With the implementation of routine immunisation programs, high and maintained vaccination coverages for many vaccine-preventable diseases—such as those against poliomyelitis or diphtheria—have been reached in most European countries and many others. Although vaccine acceptance is often high within the general population, even in countries with high vaccination coverage a significant number of children and adults are not sufficiently vaccinated because of missed opportunities or various concerns and misperceptions.
The reasons for this ‘vaccine hesitancy’ are multifactorial, complex and vary across vaccines, time and countries/regions, and are influenced by factors such as complacency (not perceiving disease as high risk and vaccination as necessary), convenience and constraints (practical barriers), and confidence (lack of trust in safety and effectiveness). As a result, vaccination coverages against highly contagious pathogens such as measles virus are not sufficient to prevent outbreaks and infectious disease spread in many countries today.
Despite the World Health Organization (WHO)’s goal to eliminate measles, a constant increase in measles cases has occurred in recent years. In 2018, more than 82,500 people in 47 of the 53 countries in the WHO European Region were infected with measles, leading to 72 deaths. These numbers were the highest in a decade. They were three times higher than in 2017 and 15 times higher than in 2016, when numbers were at a record low.
In 2019, the situation seems to be even worse, indicating that current plans of action in the affected areas are insufficient to stop measles circulation. This is evidenced by the fact that the estimated coverage with the second dose of a measles-containing vaccine is far below the necessary 95% to achieve herd/population immunity in several European countries.
In order to maintain or improve the population immunity acquired by vaccination, several countries are currently revisiting their strategies and discussing changes in vaccination policies, with a focus on either educating the population and giving individuals freedom of choice or implementing mandatory vaccination to ensure high coverage rates.
With increasing calls to introduce mandatory vaccination programs, intense debates on their effectiveness have also started in several European countries. There are concerns that mandatory vaccination may lead to opposing attitudes and even less vaccine uptake, particularly in those with existing critical attitudes towards vaccines; nonetheless, other studies have disproved that implementation of compulsory vaccination led to opposing attitudes and/or had negative effects.
However, it is indisputable that with any changes in vaccination policies, intensified information strategies are necessary to improve trust, rectify perceived risks and improve access and affordability of vaccines. Moreover, it is important to note that mandatory vaccination can follow different routes depending on a country’s specific social and cultural backgrounds, as well as epidemiological situations.
Consideration of these factors can lead to implementing temporary or permanent vaccine mandates for certain vaccines (such as measles/measles-mumps-rubella (MMR) partial compulsory vaccination), for all vaccines included in a national vaccination program or for selected target groups, such as infants and children before entrance in educational settings or certain occupational groups, such as healthcare workers (HCW).
For example, in France three mandatory vaccines (against diphtheria, tetanus and poliomyelitis (DTP)) co-existed with eight recommended vaccines (against MMR, pertussis, Streptococcus pneumoniae, hepatitis B (HepB), Neisseria meningiditis serogroup C (MenC) and Haemophilus influenza (Hib)) for routine childhood immunisation up until 2017. However, misperceptions in the population, i.e. that non-mandatory vaccines are less valuable, optional or not as safe and effective as the mandatory ones, resulted in insufficient and stagnating vaccine coverages of the recommended vaccines. This growing vaccine hesitancy, as well as large outbreaks and deaths from measles, led to a change in French policy to extend the mandates to all 11 childhood vaccines.
Italy has had a similar situation, where four mandatory vaccines were in place already before 2017 (against poliomyelitis, tetanus, diphtheria and HepB). The coverage for vaccination against measles, mumps and rubella dropped country-wide from 90% to 87% between 2000–16. This, together with large measles outbreaks, led the government to extend the existing vaccine mandates to 10 mandatory vaccines (hexavalent vaccine against DTPert (pertussis)-poliomyelitis-Hib-HepB, as well as MMR and Varicella (V) vaccine) in 2017, whereas vaccination against Men C, S. pneumoniae and rotavirus remained recommended vaccines.
The current issue of Eurosurveillance presents articles from France and Italy on approaches and experiences after the extension of mandatory vaccination. While an article in last week’s issue of Eurosurveillance by Mathieu et al describes the population’s general attitude towards mandatory vaccination shortly before implementation of extended vaccination mandates in France, the rapid communication by Lévy-Bruhl et al. in this issue evaluates the effects of mandatory vaccination on vaccine coverage 2 years after its implementation. D’Ancona et al., also in this issue, depict challenges in Italy in the year following the introduction of the new mandate and how these are being addressed.
