Head To Head

# Should childhood vaccination be mandatory? No

BMJ 2012; 344 (Published 15 May 2012) Cite this as: BMJ 2012;344:e2435
1. David M Salisbury, director of immunisation
1. 1Department of Health, London SE1 8UG, UK
1. david.salisbury{at}dh.gsi.gov.uk

Paul Offit (doi:10.1136/bmj.e2434) believes that mandatory vaccination is needed to protect vulnerable people from infection, but David Salisbury argues that there are more workable ways to ensure high uptake

Mandatory vaccination in the UK was attempted first in the 19th century.1 The legislation was ineffective, discriminated in favour of those able to use the exemptions, and was divisive; it fostered substantial anti-vaccine sentiment and was counterproductive. 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.

Two questions need to be answered: do we need mandatory vaccination and are there examples of it being beneficial?

## Compulsion is unnecessary

I presume that the purpose of mandatory vaccination is to raise coverage. If coverage is sufficiently high, compulsion is not needed. If coverage were not adequately high, other interventions are more likely to be successful than compulsion. We have reasonable ideas of what “sufficiently high” means: polio outbreaks do not occur when coverage is consistently above 80% in all localities; pertussis and diphtheria outbreaks do occur when coverage falls below those levels.2 3 Coverage against measles needs to be even higher because of its intense transmissibility. Between 1998 and 2010, the peak age for measles cases in England and Wales was less than 5 years,4 and if vaccination were made compulsory for school entry the law would be coming into effect after many infections had occurred.

Vaccination coverage can be raised to levels that prevent disease through improvements in the processes of providing vaccination services. Data for England show that coverage of the third dose of the diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae b (DTaP/IPV/Hib) vaccine by the first birthday rose progressively from 90.1% in June 2007 to 94.4% in September 2011.5 This increase was driven especially by improvements in London (79.6% to 90.5%), where there have been efforts to improve both the immunisation service and the accuracy of the data, and nationally, by the application of “vital signs”—local operational plans to deliver services against national priorities.6 Data from other European countries without mandatory immunisation also point to high coverage being achievable and sustainable (see, for example, the Netherlands, Sweden, Norway, and Denmark).7

## Evidence is unconvincing

The hostile reporting, polarised views, and credibility given to ill informed opinions after claims of a link between autism and the measles, mumps, and rubella (MMR) vaccine in the late 1990s led to national immunisation coverage falling by just over 10%.8 But the option of compulsory MMR vaccination was never considered—it would probably have made matters much worse.

Few reports show clearly that the existence of compulsion has raised and sustained immunisation coverage. The experience of the US is often quoted. All US states have laws that make proof of immunisation a prerequisite for school entry, and this is reported to be linked to high coverage, especially for MMR vaccine.1 However, exemptions to the state laws are easily obtained on the basis of religious or personal beliefs. Although around 1-3% of US children have been exempted from vaccine requirements, schools in some communities have exemption rates as high as 15-20%, and the rate of exemptions is increasing.9 Exempted children have been found to be 22-35 times more likely to get measles than vaccinated children.10 Between 1999 and 2007, there was a 74% increase in home schooling in the US, with 1.5 million children estimated to be schooled at home11: most states do not monitor the vaccination of home schooled children.12 Although national US MMR coverage has not fallen as it did in the UK, and this preservation has been credited to mandates, the US did not experience the high profile repeated reporting of the possibilities of risks from MMR vaccine that was seen in the UK.

The Australian approach is different. In response to reportedly low immunisation coverage, a plan was put in place in 1997 that included financial incentives for parents to have their children vaccinated13; payment can still be made to families that are conscientious objectors to immunisation. The payment was initially $A258 (£168; €200;$268) but in 2011, stronger incentives were announced such that completed immunisation is worth \$A2100.14 Although conscientious objection is still permissible without forfeiting payments, significantly raising payments may provoke contrary attitudes about the acceptability of this approach as it may be seen as financial coercion. If objectors still receive the payments, its function as an incentive may be hard to establish.

In 2003, in a sample of more than 1000 parents of young children in England, around half said that they sought information before immunising their children. The other half said they automatically immunised their children when due.15 In 2010, three quarters said they automatically immunised their children when due. When coverage is already high and rising, target diseases are under excellent control (although measles could be better), and parental acceptance for immunisation is high, compulsion seems a heavy hammer. Compulsion would be unenforceable, unnecessary, and its use would probably do more harm than good.

## Notes

Cite this as: BMJ 2012;344:e2435

## Footnotes

• Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; DMS is employed by the Department of Health but the views expressed here should not be taken as Department of Health policy; he has no other relationships or activities that could appear to have influenced the submitted work.

• Provenance and peer review: Commissioned; not externally peer reviewed.

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