from 90.2% to 92.9% [9]. However, this decline was not uniform,
and left major geographic exemptions clusters undisturbed [11].
Subsequently, Senate Bill 277 (enacted June 30, 2015) elimi-
nated access to NMEs entirely in California [12]. With this new
law, California joined West Virginia and Mississippi as the only
US states not to provide NMEs [7]. Advocates argued that eliminat-
ing NMEs was necessary to further increase California’s immuniza-
tion coverage [13]. However, it seems likely that they were also
motivated by the high-profile 2014–15 Disneyland measles out-
break [9,14], which may explain why the Bill’s authors (Richard
Pan and Ben Allen) were unwilling to wait to see the impact of
the earlier Assembly Bill 2109 on California’s NME rates (outlined
above) [9].
While there is some preliminary evidence that SB 277 has fur-
ther increased immunization coverage beyond the gains realized
by AB 2109, questions remain about enforcement and unintended
consequences. Financially vulnerable private schools may decide
not to enforce immunization requirements rather than risk school
closure due to declining tuition revenues from vaccine refusers
[15]. Some physicians may support marginal or fraudulent claims
for medical exemptions, which likely explains why medical exemp-
tion rates in California have tripled since the passage of Senate Bill
277 [16]. Also, Senate Bill 277 may cultivate political polarization
surrounding vaccination policy and science: most Democrats in
the California Senate voted for it, while most Republicans voted
against it, reversing a history of bipartisan vaccination policies in
the US [17].
3.2. Italy
Italy has a history of mandates for some vaccines for older chil-
dren, including diphtheria (1939), polio (1966), tetanus (1968), and
hepatitis B (1991). Mandated vaccines were offered at no cost, and
statutes authorized fines and school exclusion for children who did
not receive them. Persistent parents, however, could receive per-
mission for non-compliant children to enrol in school, after parents
attended meetings with public health officers or the Minors Court.
Fines were rarely applied. A suite of additional ‘recommended’ vac-
cines were also offered for free, notably MMR and pertussis.
Policy shifts occurred from 1999 onwards, with a Ministry of
Education decree that children who had not received mandatory
vaccinations should still be allowed to attend school. This was
based on Italy’s constitution, in which a right to education is equal
to the right to health. From here, mandates remained ‘on the
books’, but not enforced.
In 2007, the Veneto region piloted a mandate suspension,
reflecting popular opinion that the state ought to affirm the impor-
tance of vaccination, but not mandate it [18]. However, in 2013, a
local court in Rimini ruled that vaccines caused a child’s autism,
which prompted significant media coverage and internet search
activity [19]. The subsequent 2015 overturning of the case did
not receive the same media coverage [20]. Starting from 2013,
nation-wide vaccination coverage dropped significantly (Fig. 2).
In 2016 a cross-sectional survey showed that 15.6% of Italian par-
ents were vaccine hesitant and 0.7% strongly vaccine opposed [21].
Table 1
Characteristics of recent vaccine mandates.
Jurisdiction Implementation
date
Antigens covered Key reason for policy
change
Policy development
process
Exemptions Penalties/
enforcement
Gaps
California January 2016 Diphtheria, Hepatitis B,
Measles, Mumps,
Pertussis, Polio, Rubella,
Tetanus, Varicella
Large numbers of
personal belief
exemptions;
Disneyland measles
outbreak (2014–5)
Professional society
lobbying; participation
of State Senator Pan
(physician) produced
quick legislative
response
Medical only Exclusion from
daycare and
school
Children cared
for/schooled at
home
Italy Jul 2017 Diphtheria, Hepatitis B,
Hib, Measles, Mumps,
Pertussis, Polio, Rubella,
Tetanus, Varicella
Declining rates
following increasing
vaccine hesitancy
Ministry of Health
decision (Government
Decree)
Medical only Exclusion from
daycare and
pre-school (3–5
years); fines
€100-€500
Children cared
for at home. No
consequence
after initial fine
for children 6–
16 years
France Jan 2018 Diphtheria, Hepatitis B,
Hib, Measles,
Meningococcal C,
Mumps, Pertussis,
Pneumococcol, Polio,
Rubella, Tetanus
Coexistence of
mandatory and
recommended
vaccines; conclusion
of the consultation;
court case hastens
harmonisation
Comprehensive
consultation including
citizen’s juries; several
reports;Government
decision, parliament
hearing and vote
Medical only Exclusion from
daycare, school,
holiday camps.
Potential legal
proceedings for
damages
Children cared
for at home
Australia January 2016 Diphtheria, Hepatitis B,
Hib, Measles,
Meningococcal C,
Mumps, Pertussis,
Pneumococcal, Polio,
Rubella, Tetanus,
Varicella
Media lobbying;
Pertussis deaths
Parliamentary hearing,
including consultation
with experts/key
stakeholders and
consideration of
submissions from
general public
Medical; other
limited
exemptions
Loss of up to
$8350/year in
financial
assistance
High income
earners; but
annual
consequence
for others
Washington July 2011 Diphtheria, Hepatitis B,
Measles, Mumps,
Pertussis, Polio, Rubella,
Tetanus, Varicella
One of the highest
rates of personal
belief exemptions in
USA; Pertussis
outbreaks 2010
State Health
Department request;
stakeholder advocacy
Religious,
personal belief
after medical
counselling
Exclusion from
daycare and
school unless
exemption
obtained
Children cared
for/schooled at
home. Those
who claim
appropriate
religious
affiliation
Germany June 2017 Diphtheria, Hepatitis B,
Hib, HPV, Measles,
Meningococcal C,
Mumps, Pertussis,
Pneumococcal, Polio,
Rotavirus, Rubella,
Tetanus, Varicella
Measles outbreaks Government led action
plan involving key
stakeholders
Must provide
form at day
care entry; no
exemption for
form but vax
not required
Up to €2500
fine
Children cared
for at home. No
consequence
after initial fine
K. Attwell et al. / Vaccine xxx (2018) xxx–xxx 3
Please cite this article in press as: Attwell K et al. Recent vaccine mandates in the United States, Europe and Australia: A comparative study. Vaccine (2018),
https://doi.org/10.1016/j.vaccine.2018.10.019

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