Should childhood vaccination be mandatory?

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Immunising healthy children helps to build herd immunity making immunisation part of a ‘social contract’ which sees the healthy majority protecting the small minority of children for whom vaccination is not an option for medical reason.

However, the prospect of mandating vaccination has always raised awkward questions about autonomy and freedom of choice.

This contentious issue has been resurrected in recent weeks by Dr Paul Offit, Chief of Infectious Diseases at the Children’s Hospital of Philadelphia. Writing in the British Medical Journal, he argues that mandatory vaccination is the most effective way to protect vulnerable people from potentially dangerous contagious diseases.

Dr Offit notes that parents’ immunisation decisions have consequences for their own children, but also for other children, such as those who are too young to receive vaccines or who cannot be vaccinated for health reasons.

In Dr Offit’s view, the stakes are too high to accept sub-optimal vaccine uptake rates, a phenomenon he attributes in part to false claims which undermine vaccine safety

“Someday we may live in a world that doesn’t scare patients into making bad health decisions. Until then, vaccine mandates are the best way to ensure protection from illnesses that have caused so much needless suffering and death,” he says.

‘Mandates make matters worse’

Not so fast, says Prof David Salisbury, Director of Immunisation at the UK Department of Health. While he agrees that immunisation is essential to safeguarding children’s health and is concerned about ongoing outbreaks of measles, Prof Salisbury says forcing people to be vaccinated may send the wrong message.

Even at the height of the MMR scare in the UK, which saw the measles vaccine falsely linked to autism, compulsory vaccination was never contemplated, he says. Given the sensitivities over vaccines at that time, vaccine mandates “would probably have made matters worse” by fostering anti-vaccine sentiment.

Prof Salisbury says “compulsion would be unenforceable and unnecessary”, arguing that improving vaccine services can help boost uptake.

He notes that mandatory vaccination was first attempted in the 19th century but, even at that time, the legislation was ineffective and divisive.

“Attempts to impose compulsion today would undoubtedly be challenged in terms of autonomy, inappropriate intrusion of the state, availability of choice, and parental rights and responsibilities. Bolstered by access to information, its unacceptability to the public would be likely to have the same consequences,” Prof Salisbury wrote.

In any case, he adds, vaccination coverage is currently high in the UK for most diseases and parental acceptance of childhood immunisation is the norm so compulsory vaccination “seems a heavy hammer”.

Social contract

Dr Dina Pfeifer of WHO Europe says parents have a responsibility to immunise their children but, if they choose “not to contribute to community health”, they should be transparent about this so that measures can be taken to protect other children in the event of an outbreak.

Of course, the issue of mandatory vaccination is wider than the debate about childhood immunisations. In the US, flu vaccination for health workers is effectively mandatory in several hospitals. An expert group which advises the government has recommended that hospitals should make flu vaccination a condition of employment if they cannot convince at least 90% of staff to be immunised.

Whether such a policy would ever become widespread in Europe is an open question, not least due to the diversity between national cultures.

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