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Recent vaccine mandates in the United States, Europe and Australia:
A comparative study
Katie Attwell a,⇑, Mark C. Navin b
, Pier Luigi Lopalco c , Christine Jestin d , Sabine Reiter e
, Saad B. Omer f
a Political Science and International Relations, University of Western Australia, 35 Stirling Highway, Crawley 6009, Australia
b Department of Philosophy, Oakland University, 146 Library Drive, Rochester, MI 48309-4479, USA
c Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Lungarno Antonio Pacinotti, 43, 56126 Pisa Pl, Italy
d Sante Publique France, 12 rue du Val d’Osne, 94415 Saint-Maurice Cedex, France
e Infectious Diseases, Antimicrobial Resistance, Hygiene, Vaccination Federal Ministry of Health, Bundesministerium für Gesundheit Referat, 322 Friedrichstraße 108, 10117
Berlin, Germany
f Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 20211, USA
a r t i c l e i n f o
Article history:
Received 18 June 2018
Received in revised form 3 October 2018
Accepted 4 October 2018
Available online xxxx
Keywords:
Vaccination
Immunization
Mandatory
Mandates
Policy
a b s t r a c t
Background: In response to recent outbreaks of vaccine-preventable diseases and concerns around vac-
cine refusal, several high-income countries have adopted or reformed vaccine mandate policies. While
all make it more difficult for parents to refuse vaccines, the nature and scope of ‘mandatory vaccination’
is heterogeneous, and there has been no attempt to develop a detailed, comparative systematic account
of the possible forms mandates can take.
Methods: We compare the construction, introduction/amendment, and operation of six new high profile
vaccine mandates in Australia, France, Germany, Italy, California, and Washington. We rank these policies
in order of their relative restrictiveness and analyze other differences between them.
Results: New mandate instruments differ in their effects on behavior, and with regard to their structure,
exemptions, target populations, consequences and enforcement. We identify diverse means by which
vaccine mandates can restrict behaviors, various degrees of severity, and different gradations of intensity
in enforcement.
Conclusion: We suggest that politico-cultural context and vaccine policy history are centrally important
factors for vaccine mandate policymakers to consider. It matters whether citizens trust their govern-
ments to limit individual freedom in the name of public health, and whether citizens have previously
been subjected to vaccine mandates. Furthermore, political communities must consider the diverse
mechanisms by which they may construct vaccine mandate policies; whether through emergency
decrees or ordinary statutes, and how (or whether) to involve various stakeholder groups in developing
and implementing new vaccine mandate policies.
Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction
Outbreaks of vaccine preventable diseases have recently
occurred in many countries, e.g. measles in France, mumps in Ire-
land, and pertussis in the US. Several governments have responded
by introducing or strengthening vaccine mandates; other jurisdic-
tions are considering similar policies. Mandate instruments are
heterogeneous in how they operate to organise and change behav-
ior, with regard to structure, exemptions, target populations, con-
sequences and enforcement. Yet the nature and scope of
‘mandatory vaccination’ is indeterminate, and there has not yet
been a systematic comparative synthesis of mandate policy devel-
opment, implementation and structure. Debates about vaccine
mandates ought to be informed by accurate accounts of the diverse
aims and requirements that vaccine mandate policies involve. In
this article, we compare new vaccine mandate policies adopted
in four countries and two US states in the last two years. We have
chosen our case studies as high profile exemplars of policy changes
in response to vaccine rejection and/or disease outbreaks; policy-
makers within these jurisdictions reference each other’s policies
as trends or templates [1]. We outline these new mandatory
policies in order of their relative restrictiveness, based on how dif-
ficult they make it for parents to refuse vaccines for their children.
Our comparison yields clear lessons for jurisdictions considering
implementing or reforming vaccine mandates, including a need
https://doi.org/10.1016/j.vaccine.2018.10.019
0264-410X/Ó 2018 Elsevier Ltd. All rights reserved.
⇑ Corresponding author.
E-mail address: Katie.attwell@uwa.edu.au (K. Attwell).
Vaccine xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Vaccine
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / v a c c i n e
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
A comparative study
Katie Attwell a,⇑, Mark C. Navin b
, Pier Luigi Lopalco c , Christine Jestin d , Sabine Reiter e
, Saad B. Omer f
a Political Science and International Relations, University of Western Australia, 35 Stirling Highway, Crawley 6009, Australia
b Department of Philosophy, Oakland University, 146 Library Drive, Rochester, MI 48309-4479, USA
c Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Lungarno Antonio Pacinotti, 43, 56126 Pisa Pl, Italy
d Sante Publique France, 12 rue du Val d’Osne, 94415 Saint-Maurice Cedex, France
e Infectious Diseases, Antimicrobial Resistance, Hygiene, Vaccination Federal Ministry of Health, Bundesministerium für Gesundheit Referat, 322 Friedrichstraße 108, 10117
Berlin, Germany
f Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 20211, USA
a r t i c l e i n f o
Article history:
Received 18 June 2018
Received in revised form 3 October 2018
Accepted 4 October 2018
Available online xxxx
Keywords:
Vaccination
Immunization
Mandatory
Mandates
Policy
a b s t r a c t
Background: In response to recent outbreaks of vaccine-preventable diseases and concerns around vac-
cine refusal, several high-income countries have adopted or reformed vaccine mandate policies. While
all make it more difficult for parents to refuse vaccines, the nature and scope of ‘mandatory vaccination’
is heterogeneous, and there has been no attempt to develop a detailed, comparative systematic account
of the possible forms mandates can take.
Methods: We compare the construction, introduction/amendment, and operation of six new high profile
vaccine mandates in Australia, France, Germany, Italy, California, and Washington. We rank these policies
in order of their relative restrictiveness and analyze other differences between them.
Results: New mandate instruments differ in their effects on behavior, and with regard to their structure,
exemptions, target populations, consequences and enforcement. We identify diverse means by which
vaccine mandates can restrict behaviors, various degrees of severity, and different gradations of intensity
in enforcement.
Conclusion: We suggest that politico-cultural context and vaccine policy history are centrally important
factors for vaccine mandate policymakers to consider. It matters whether citizens trust their govern-
ments to limit individual freedom in the name of public health, and whether citizens have previously
been subjected to vaccine mandates. Furthermore, political communities must consider the diverse
mechanisms by which they may construct vaccine mandate policies; whether through emergency
decrees or ordinary statutes, and how (or whether) to involve various stakeholder groups in developing
and implementing new vaccine mandate policies.
Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction
Outbreaks of vaccine preventable diseases have recently
occurred in many countries, e.g. measles in France, mumps in Ire-
land, and pertussis in the US. Several governments have responded
by introducing or strengthening vaccine mandates; other jurisdic-
tions are considering similar policies. Mandate instruments are
heterogeneous in how they operate to organise and change behav-
ior, with regard to structure, exemptions, target populations, con-
sequences and enforcement. Yet the nature and scope of
‘mandatory vaccination’ is indeterminate, and there has not yet
been a systematic comparative synthesis of mandate policy devel-
opment, implementation and structure. Debates about vaccine
mandates ought to be informed by accurate accounts of the diverse
aims and requirements that vaccine mandate policies involve. In
this article, we compare new vaccine mandate policies adopted
in four countries and two US states in the last two years. We have
chosen our case studies as high profile exemplars of policy changes
in response to vaccine rejection and/or disease outbreaks; policy-
makers within these jurisdictions reference each other’s policies
as trends or templates [1]. We outline these new mandatory
policies in order of their relative restrictiveness, based on how dif-
ficult they make it for parents to refuse vaccines for their children.
Our comparison yields clear lessons for jurisdictions considering
implementing or reforming vaccine mandates, including a need
https://doi.org/10.1016/j.vaccine.2018.10.019
0264-410X/Ó 2018 Elsevier Ltd. All rights reserved.
⇑ Corresponding author.
E-mail address: Katie.attwell@uwa.edu.au (K. Attwell).
Vaccine xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Vaccine
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / v a c c i n e
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
to pay attention to political and policy considerations of path
dependency.
2. Mandates come in different shapes and sizes
Courts in countries around the world have long recognized the
legitimacy of liberty-infringing public health efforts, in light of the
priority that communities place on avoiding disease [2,3]. Such
efforts include vaccine mandates, which have only rarely been
overturned by courts [1]. When considering mandates, policymak-
ers must address divergent access and acceptance reasons that
populations may remain under-vaccinated. Access refers to the
availability, affordability and convenience of services; parental
complacency may also fit here. Acceptance, by contrast, relates to
vaccine hesitancy [4]. Parents fear ingredients, distrust authorities,
or do not regard vaccination as congruent with their parenting
practices [5]. Vaccine mandates can address acceptance by making
it harder – or more consequential – for parents to refuse vaccines.
However, mandates govern access (complacency) too, as we
explain below.
We can better understand jurisdictions’ vaccine mandates by
locating them on an ideal-type continuum (Fig. 1). At one end, vac-
cination is voluntary, and state interventions merely nudge or per-
suade individuals to vaccinate. At the other end, vaccine refusers
are fined or imprisoned. Here, the state’s coercive power motivates
individuals to utilise available vaccination services.
Between these ends of the continuum are positively framed
requirements. The first links vaccine uptake to public goods such
as state-subsidised daycare and public schools, while the second
links uptake to financial incentives. Both function as ‘carrots’ that
only the vaccinated can obtain; compliers are offered a benefit
which is denied to non-compliers.
We can then differentiate ‘carrot’ policies on the basis of
exemptions. Towards the voluntary end of the spectrum, compli-
ance means an individual attains the benefit, but non-compliers
can obtain it after performing specified actions. This overcomes
complacency, whilst constructing an exemption process for non-
compliers to follow. Towards the coercive end of the spectrum,
exemption processes are removed (except in the case of medical
contra-indications to vaccination). As ‘carrot’ policies move along
the spectrum towards coercion, there is no change to the
governance of compliers, who might have access barriers or need
motivation. However, vaccine rejection meets consequences that
cannot be ‘worked around’ with exemptions. In the next section,
we compare mandate policies in six jurisdictions that have
recently introduced or strengthened them, starting with what we
rank as the most restrictive and moving to the least restrictive poli-
cies. We note that while we use a terminology of restrictiveness,
other scholars have recently employed a terminology of rigidity
(from hard to soft) [6].
3. Country case studies
3.1. California
All US states require children to receive vaccines to attend day-
care or school (specific vaccines for the states in this study are
listed in Table 1). Since September 23, 2010, the Affordable Care
Act has required vaccines recommended by the Advisory Commit-
tee on Immunization Practices (ACIP) to be covered by insurance.
The Vaccines for Children Program (a federally-funded and state-
administered program) provides free vaccines for children who
are uninsured or Medicaid eligible. Most US states permit parents
and guardians to receive nonmedical exemptions (NMEs) to immu-
nization mandates [7]. A 2010 national survey of US parents found
that 77% of parents with children aged 1–6 had a vaccine concern,
which included beliefs that vaccine ingredients may be unsafe
(26%) and that vaccines may cause learning disabilities such as aut-
ism (30%). In light of rising NME rates in California, the state legis-
lature recently passed two laws to successively restrict parents’
access to them.
Assembly Bill 2109 (in effect January 1, 2014 to January 1, 2016)
made it more difficult for parents or guardians to receive NMEs by
requiring applicants to submit an official state form on which a
physician attested that they provided information regarding the
benefits/risks of immunization [8]. At the time of Assembly Bill
2109’s introduction, 90.2% of entering Kindergarteners were up-
to-date on all required vaccines. The rate of nonmedical exemp-
tions was 3.1% [9]. Assembly Bill 2109 aimed to reduce NME rates
by targeting the complacent; parents and guardians with only
moderate objections might decide to vaccinate rather than
complete burdensome paperwork, as previous research indicated
was likely [10]. Assembly Bill 2109 was associated with a 25%
reduction in California’s NME rates (from 3.1% to 2.3%), and signif-
icant increases up-to-date status for entering Kindergarteners,
Fig. 1. The conceptual continuum of options available to policymakers for vaccine mandates.
2 K. Attwell et al. / Vaccine xxx (2018) xxx–xxx
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
dependency.
2. Mandates come in different shapes and sizes
Courts in countries around the world have long recognized the
legitimacy of liberty-infringing public health efforts, in light of the
priority that communities place on avoiding disease [2,3]. Such
efforts include vaccine mandates, which have only rarely been
overturned by courts [1]. When considering mandates, policymak-
ers must address divergent access and acceptance reasons that
populations may remain under-vaccinated. Access refers to the
availability, affordability and convenience of services; parental
complacency may also fit here. Acceptance, by contrast, relates to
vaccine hesitancy [4]. Parents fear ingredients, distrust authorities,
or do not regard vaccination as congruent with their parenting
practices [5]. Vaccine mandates can address acceptance by making
it harder – or more consequential – for parents to refuse vaccines.
However, mandates govern access (complacency) too, as we
explain below.
We can better understand jurisdictions’ vaccine mandates by
locating them on an ideal-type continuum (Fig. 1). At one end, vac-
cination is voluntary, and state interventions merely nudge or per-
suade individuals to vaccinate. At the other end, vaccine refusers
are fined or imprisoned. Here, the state’s coercive power motivates
individuals to utilise available vaccination services.
Between these ends of the continuum are positively framed
requirements. The first links vaccine uptake to public goods such
as state-subsidised daycare and public schools, while the second
links uptake to financial incentives. Both function as ‘carrots’ that
only the vaccinated can obtain; compliers are offered a benefit
which is denied to non-compliers.
We can then differentiate ‘carrot’ policies on the basis of
exemptions. Towards the voluntary end of the spectrum, compli-
ance means an individual attains the benefit, but non-compliers
can obtain it after performing specified actions. This overcomes
complacency, whilst constructing an exemption process for non-
compliers to follow. Towards the coercive end of the spectrum,
exemption processes are removed (except in the case of medical
contra-indications to vaccination). As ‘carrot’ policies move along
the spectrum towards coercion, there is no change to the
governance of compliers, who might have access barriers or need
motivation. However, vaccine rejection meets consequences that
cannot be ‘worked around’ with exemptions. In the next section,
we compare mandate policies in six jurisdictions that have
recently introduced or strengthened them, starting with what we
rank as the most restrictive and moving to the least restrictive poli-
cies. We note that while we use a terminology of restrictiveness,
other scholars have recently employed a terminology of rigidity
(from hard to soft) [6].
3. Country case studies
3.1. California
All US states require children to receive vaccines to attend day-
care or school (specific vaccines for the states in this study are
listed in Table 1). Since September 23, 2010, the Affordable Care
Act has required vaccines recommended by the Advisory Commit-
tee on Immunization Practices (ACIP) to be covered by insurance.
The Vaccines for Children Program (a federally-funded and state-
administered program) provides free vaccines for children who
are uninsured or Medicaid eligible. Most US states permit parents
and guardians to receive nonmedical exemptions (NMEs) to immu-
nization mandates [7]. A 2010 national survey of US parents found
that 77% of parents with children aged 1–6 had a vaccine concern,
which included beliefs that vaccine ingredients may be unsafe
(26%) and that vaccines may cause learning disabilities such as aut-
ism (30%). In light of rising NME rates in California, the state legis-
lature recently passed two laws to successively restrict parents’
access to them.
Assembly Bill 2109 (in effect January 1, 2014 to January 1, 2016)
made it more difficult for parents or guardians to receive NMEs by
requiring applicants to submit an official state form on which a
physician attested that they provided information regarding the
benefits/risks of immunization [8]. At the time of Assembly Bill
2109’s introduction, 90.2% of entering Kindergarteners were up-
to-date on all required vaccines. The rate of nonmedical exemp-
tions was 3.1% [9]. Assembly Bill 2109 aimed to reduce NME rates
by targeting the complacent; parents and guardians with only
moderate objections might decide to vaccinate rather than
complete burdensome paperwork, as previous research indicated
was likely [10]. Assembly Bill 2109 was associated with a 25%
reduction in California’s NME rates (from 3.1% to 2.3%), and signif-
icant increases up-to-date status for entering Kindergarteners,
Fig. 1. The conceptual continuum of options available to policymakers for vaccine mandates.
2 K. Attwell et al. / Vaccine xxx (2018) xxx–xxx
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
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
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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