January 13, 2020
3 min read

Vaccine mandates boost coverage in Europe

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Mallory K. Ellingson, MPH, PhD  
Mallory K. Ellingson
Peter J. Hotez, MD, PhD 
Peter J. Hotez

European countries that mandated vaccination and imposed stiffer financial penalties for noncompliance had higher vaccination coverage against measles and pertussis, according to a study covering 29 European countries published in Pediatrics.

“Clinicians should be aware of the vaccine mandate policy in their state or country and be prepared to discuss it with patients,” Mallory K. Ellingson, MPH, PhD student in the department of epidemiology of microbial diseases at the Yale School of Public Health , told Healio. “Our findings add to the existing body of literature in support of the use of vaccine mandates generally as a tool to improve vaccination rates.”

In the United States, vaccine exemption rates among kindergarteners steadily rose during the 2018-2019 school year. Although vaccine laws in California introduced in 2015 have improved vaccine uptake among kindergarteners in that state, laws banning personal belief exemptions for children have shown only modest results.

“Since 2016 we've seen a marked increase in the number of measles cases in both Europe and the United States, with some numbers in Europe indicating that more than 100,000 cases occurred in 2019,” Peter J. Hotez, MD, PhD, professor of pediatrics and dean of the National School of Tropical Medicine at Baylor College of Medicine, told Healio. “Much of this rise is due to the spread of vaccine hesitancy, in part because of expanding bandwidth of an anti-vaccine movement that began in the early 2000s.”

Sean T. O’Leary, MD, MPH 
Sean T. O’Leary
Yvonne  Maldonado 
Yvonne A. Maldonado

Impact on vaccine coverage, disease incidence

Using data from the European CDC and WHO, researchers examined whether a country’s mandatory vaccination policies had an impact on measles and pertussis vaccine coverage and the annual disease incidence in Europe.

Mandatory vaccination was associated with a 3.71 (95% CI, 1.68-5.74) percentage point increase in the prevalence of measles vaccination and a 2.14 (95% CI, 0.13-4.15) percentage point increase in pertussis vaccination compared with countries without mandatory vaccination laws, researchers said. However, mandatory vaccination was associated with a decrease in measles incidence only in countries that prohibited nonmedical exemptions (adjusted incidence rate ratio = 0.14; 95% CI, 0.05-0.36), and no significant association was found between mandatory vaccination and the incidence of pertussis.

Mandatory vaccination was associated with a 3.71 percentage point increase in prevalence of measles vaccination and a 2.14 percentage point increase in pertussis vaccination in European countries with mandatory vaccination policies.
Source: Adobe Stock

Although mandatory vaccination overall did not have an impact on the incidence of both diseases, financial penalties did. Countries that imposed fines had incidence rates of less than half that of countries without mandatory vaccination policies for measles and pertussis. Researchers also said that among countries that impose a fine for noncompliance by parents, every 500 euro increase in the maximum possible penalty was associated with an increase of 0.8 points for measles vaccination coverage (95% CI, 0.5-1.15) and an increase of 1.1 percentage points for pertussis vaccination coverage (95% CI, 0.95-1.3).


Ellingson noted that one of the study’s major limitations was its cross-sectional design, which meant that only current vaccine policies were included for analysis.

“To really know what impact a change in vaccine policy can have, both researchers and policy makers should carefully monitor vaccine acceptance rates and vaccine attitudes whenever there is a change in vaccine policy,” Ellingson said.

‘Crises of their own making’

“It is unfortunate that in 2019, highly resourced regions, such as the United States and Europe, continue to struggle with health crises of their own making,” Sean T. O’Leary, MD, MPH, associate professor of pediatric infectious diseases at the University of Colorado School of Medicine, and Yvonne A. Maldonado, MD, professor of pediatric infectious diseases at Stanford School of Medicine, wrote in an accompanying editorial. “The causes of vaccine hesitancy are multifactorial, and although the scientic and medical community can conveniently point to the small but vocal group of anti-vaccination activists as the cause of this health crisis, we must also consider how to best address the root causes of this pervasive movement.”

Hotez, who was not involved with the study, noted that public opinion is important in improving vaccination rates.

“Changing policies and laws will not change hearts and minds, and for that we'll need to simultaneously create a more robust system of advocacy for vaccines, especially for routine childhood immunizations and for the HPV vaccine,” Hotez said. – by Eamon Dreisbach


O’Leary ST, et al. Pediatrics. 2020;doi:10.1542/peds.2019-2436.

Vaz OM, et al. Pediatrics. 2020;doi:10.1542/peds.2019-0620.

Disclosures: Ellingson, Hotez, O’Leary and Maldonado report no relevant financial disclosures.