Global assessment of national mandatory vaccination policies and consequences of non-compliance

Abstract

Background: Declining vaccination coverage and increasing hesitancy is a worldwide concern. Many countries have implemented mandatory vaccination policies to promote vaccination. However, mandatory vaccination policies differ significantly by country. Beyond case studies, no comprehensive study has compared these policies or the penalties for non-compliance on a global scale.

Methods: We conducted extensive keyword, policy, and literature searches to identify mandatory national vaccination policies globally and develop a comprehensive database. A mandatory national vaccination policy was defined as a policy from a national authority that requires individuals to receive at least one vaccination based on age or to access a service. Two reviewers independently evaluated evidence for a mandate and whether non-compliance penalties were incorporated. We categorized penalties into four types, based on the nature of the penalty. These penalties impact an individual's financial, parental rights, educational (i.e., child's school entry and access), and liberty status. We rated the severity within each category.

Results: Of 193 countries investigated, 54% (n = 105) had evidence of a nationwide mandate as of December 2018. The frequency, types, and severity of penalties varied widely across all regions. We found that 59% (n = 62) of countries with national mandates defined at least one penalty for non-compliance with a vaccine mandate. Among those, educational penalties (i.e., limiting a child's entry or ongoing access to school) were the most common (69%; n = 43), with most countries with educational penalties refusing school enrollment until vaccination requirements are met (81%; n = 35).

Conclusion: We undertook a comprehensive assessment of national mandatory vaccination policies and identified a diversity of penalties in place to promote compliance. Our results highlight the need to critically evaluate the implementation of non-compliance penalties in order to determine their effectiveness and to define best practices for sustaining high vaccination uptake worldwide.

Keywords: Compliance; Mandatory; Penalties; Policy; Vaccination; Vaccine hesitancy; Vaccines.

Fig. 1.

Research process for identifying and categorizing national mandatory vaccination policies and associated penalties for non-compliance.

Fig. 2.

Classification scheme used in this global analysis of national mandatory vaccination policies to categorize the severity of each penalty type for: (a) financial penalties; (b) parental penalties; (c) educational penalties; (d) liberty penalties.

Fig. 3.

Distribution of national mandatory vaccination policies globally, further categorized based on whether evidence was obtained that the policy includes penalties for non-compliance.

Fig. 4.

Global distribution of the types of penalties in countries with national mandatory vaccination policies for: (a) financial penalties; (b) parental penalties; (c) educational penalties; (d) liberty penalties.

Fig. 5.

Regional distribution of penalty types and severity within those types identified in countries with evidence of a national mandatory vaccination policy; (A) financial penalties; (B) parental penalties; (C) educational penalties; (D) liberty penalties.