Is mandatory vaccination the best way to tackle falling rates of childhood immunisation?

30 September 2019

Portrait of Dr Alberto Giubilini

by Dr Alberto Giubilini
Postdoctoral Research Fellow

Alberto Giubilini is a Postdoctoral Research Fellow on the Oxford Martin Programme on Collective Responsibility for Infectious Disease.

Portrait of Dr Samantha Vanderslott

by Dr Samantha Vanderslott
Social Sciences Researcher

Samantha is a Social Sciences Researcher at the Oxford Vaccine Group and the Oxford Martin School, working within the Programme on Collective Responsibility for Infectious Disease.

Adobe Stock 169622377
Following the publication of figures showing UK childhood vaccination rates have fallen for the fifth year in a row, researchers from the Oxford Martin Programme on Collective Responsibility for Infectious Disease discuss possible responses.

Alberto Giubilini: Yes, “we need to be bold” and take drastic measures to increase vaccination uptake

In response to the dramatic fall in vaccination uptake in the UK, Health Secretary Matt Hancock has said that “we need to be bold” and that he “will not rule out action so that every child is properly protected”. This suggests that the Health Secretary is seriously considering some form of mandatory vaccination program or some form of penalty for non-vaccination, as is already the case in other countries, such as the US, Italy, France, or Australia. It is about time the UK takes action to ensure that individuals fulfil their social responsibility to protect not only their own children, but also other people, from infectious disease, and more generally to make their fair contribution to maintaining a good level of public health.

At the moment, the UK does not have any restrictive vaccination policy. It routinely offers certain vaccines through the NHS. This is not enough. For the first year on record, there has been a decline in vaccine uptake in the UK for every single vaccine routinely offered by the NHS. The uptake of the MMR (the combined measles, mumps, and rubella vaccine) has plummeted to a five-year low. Measles is a dangerous and highly infectious disease that in the UK can kill 1 in 5,000 infected individuals, and even when it is not lethal can cause severe and permanent brain damage. The health and the life of many people – including those who cannot be vaccinated for medical or age reason - is in danger if vaccination coverage rate does not rise back to the level of herd immunity. This is the situation where everyone, including the non-vaccinated, is protected by virtue of enough people in a community being immunised.

Vaccination is not only a personal choice; it is a choice that affects other people and something that individuals ultimately owe to their own community. It is a civic duty and a social responsibility. As is the case with other civic duties, legal requirements may and should be imposed on them. If properly implemented, such policies are not only fair, but also likely to be effective at raising vaccination uptake, as the cases of Italy and France suggest. Thus, the bold action advocated by Mr Hancock would be not only necessary, but ethically required.

Of course, restrictive polices cannot be the only solution. We need to figure out why vaccination rates are so low and facilitate access to vaccination. Many people who fail to vaccinate their children are not anti-vaxxers, but face barriers to accessing vaccines.

Samantha Vanderslott: No, we can be bold, but that does not mean mandatory vaccination

It is certainly very worrying that vaccination rates in England have fallen this year for all key childhood vaccines offered routinely by the NHS. In particular, the UK has lost its ‘measles-free’ status with the World Health Organisation (WHO) only three years after transmission of measles had been interrupted in this country. Whether mandatory vaccination is the best strategy to increase uptake, however, is disputable. This is not to say that mandatory vaccination would not be effective – what is at stake is the type of health system we want to foster.

On the one hand, greater emphasis should be on making it as easy as possible for parents to get children vaccinated and to have the conversations needed with well-equipped health professionals. These types of measures are already in the government’s forthcoming vaccine strategy, recently announced by the Prime Minister. Included in the announcement were:

  • a ‘catch up’ campaign for 5-25 year olds who have not had two doses of the jab
  • strengthening the role of local immunisation coordinators,
  • a new website to better address parents’ concerns on vaccines,
  • a summit to discuss the role social media companies can play.

All of these measures are welcomed but need to be fully enabled through increased investment and support for immunisation services.

On the other hand, some of the potential downsides of a mandatory vaccination programme or penalties for non-vaccination also need to be addressed. It is difficult to predict well the effects of mandates, which are blunt measures. As Omer et al argue, the relationship between policy and vaccination rates remains unclear (as in the US and Australia), and penalties could worsen inequities in access to resources and even fuel anti-vaccine activism. It is easier for politicians to talk about ‘bold action’ like mandatory vaccination but harder to commit actual funding and resources that are needed to fully realise even existing strategic pledges.

Of course, we should not forget that more drastic measures are also available in the event of a large outbreak. Although the state can no longer require a person receive medical treatment (including vaccinations), special requirements and restrictions may be put in place if there is a serious and imminent threat to public health. These include medical examinations, removal or detention in a hospital or other building, isolation or quarantine (1984 Public Health Act).

We already have many of the tools at our disposal to raise vaccine uptake. We just need to use them better.