With the widespread rollout of COVID-19 vaccines globally, some countries have started to consider mandatory vaccination, although no country has yet to make vaccines mandatory for its population.1 While COVID-19 has resurfaced the debate on vaccination policies, it has been an important topic for many other diseases. The World Health Organization (WHO) estimates that vaccines save two to three million lives each year (excluding COVID). The development of vaccines against vaccine-preventable childhood diseases has been a key driver in the decline of child mortality.
Despite it being such an important topic, it is surprising that information about which countries have mandatory vaccine policy is lacking, and it is childhood vaccines under a country’s national immunization schedules that are most commonly made mandatory.
In this article we present a new global dataset which looks at childhood vaccination policies across the world.
We recently charted mandatory childhood vaccine policies worldwide as they are becoming an increasingly important policy intervention for governments trying to address low vaccination rates.2
The term ‘mandatory’ and ‘mandates’ are taken to mean quite different things across countries. Whilst the term is commonly used it is poorly defined.3 Mandates require vaccination for a certain purpose, most commonly related to school entry for children. While definitional disagreements still persist, it remains important to better understand what policies are in place across countries and the reasons driving changes in policy over time.
Our list indicates whether a country has a mandatory vaccination policy for one or more vaccine and the strictness of the mandate on a scale ranging across three levels: mandatory, mandatory for school entry, or recommended. The childhood vaccines include the vaccines that protect from measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, rabies, hepatitis B, rotavirus, haemophilus influenzae type B, and tuberculosis – some of which are administered as combined vaccines. We have classified a country as having a mandatory policy if they mandate for at least one vaccine.
The differences in vaccination policy across the world are shown in the map. By covering 149 countries we could identify some trends around where and why vaccines are mandatory today.
Note: this is a live dataset that relies on crowdsourcing to note policy changes. If you are aware of any new policies or policy changes for any country please do get in touch at: firstname.lastname@example.org.
We found that assessing policies across WHO regions – European, Americas, Western Pacific, African, and Eastern Mediterranean – was a useful way to break down our analysis of policies worldwide.
In the chart you see a breakdown of the number of countries with a given policy mandate. You can view this by region by using the “Change region” toggle on the interactive chart.
Europe has a mixture of mandatory and recommended policies. But most European countries – 16 out of 28 – do not have mandatory vaccination. European countries were among the first to introduce mandatory vaccination for smallpox in the early 19th century, which also led to early push-back. The early introduction and early push-back, along with present-day approaches to foster mutual trust and responsibility between citizens and the health authorities, may be part of the reason why vaccination is often recommended rather than mandated in many European countries.4 Countries of the former-USSR (Union of Soviet Socialist Republics) or under the influence of the Eastern Bloc previously had mandatory vaccination, and many kept this policy in the post-USSR era.
Most countries in the Americas – 29 out of 35 – have mandatory vaccinations. In the USA, vaccination is regulated by individual states though it is mandatory for school entry in all of them. In Canada, only three provinces have legislated mandatory vaccination policies that apply to children enrolling in school.
In the Western Pacific region, changes to mandatory policies have gone in both directions. Some countries such as Singapore have moved towards mandatory vaccinations whilst others, such as South Korea transitioned away from mandatory to recommended vaccines in 1999. For other countries, mandatory policies are more ambiguous. In China, there is no evidence of specific legislation mandating vaccines, despite many references to such claims in the literature.5
It was difficult to obtain information about vaccination policies across African countries, suggesting the absence of specific policies in the region. However, the policies we did find were for mandatory vaccination.
Most countries in the Eastern Mediterranean region have mandatory vaccines. Israel is an exception in only recommending vaccination, based on a vaccination schedule outlined by the National Immunization Technical Advisory Group.
There are a number of countries in South-East Asia with mandatory vaccination. India is similar to other large countries, with varying policies on mandatory vaccination at the state level. Finally, we note that there are some countries that have mandatory policies at a sub-country level such as in Canadian provinces and Indian and Australian states but we have classified these countries as to the national policy and the policies cover most of the country.
Overall, we found that the occurrence of recent outbreaks is a major factor in the introduction of mandatory vaccination, particularly for high and upper-middle-income countries in Europe. Germany, for example, made measles vaccination mandatory for school and day-care attendance in 2020 following large outbreaks.6 Similarly, Serbia tightened mandatory vaccination laws following a measles outbreak in 2014 to 2015 by introducing harsher penalties.7 Trends of reported cases of measles can be explored in detail here.
Secondly, many low- and lower-middle-income countries have resorted to mandatory vaccination policies because of a lack of other policy options. Nonetheless, many have still missed their target vaccination rates due to problems with vaccine supply, delivery, and access. In Guyana for example, vaccination is mandatory, yet vaccination coverage is hindered by the management of the supply chain in keeping storage temperatures consistent and the distribution of freeze-sensitive vaccines.8 In Nigeria, vaccination is mandatory, and several states have enacted legislation criminalising vaccine refusal. Yet as Onyemelukwe (2016) argues, there are structural, logistical, political, systemic, religious and cultural obstacles to the effective distribution and uptake of vaccines, ranging from cold chain issues, to corruption and security issues.9 There is thus often variation between vaccination in policy compared to in practice.
These findings will be useful to inform policymakers considering the merits of mandatory vaccination:
1) In the past, an outbreak of a disease (such as measles) has led to introduction of mandatory vaccines even in countries where previously all vaccinations were recommended;
2) Making a vaccine mandatory should not be the only policy tool but needs to be combined with strong access and availability of vaccines;
3) It is not just a matter of whether to mandate a vaccine, but how this mandate will be enforced, whether people will comply, and the impact on state-citizen relations.
In summary, mandatory vaccination must be considered with caution. A country’s past experience with mandates, vaccination services, ability for enforcement, public attitudes, and the current state of disease outbreaks will all play a part in whether mandatory vaccination should be introduced.