Is It Time for Mandatory Vaccinations in Europe?

The COVID-19 pandemic has prompted a rethink of European vaccination strategies: which are the most effective?

Outbreaks of vaccine-preventable diseases over the last decade, triggered by vaccine hesitancy along with the COVID-19 pandemic, underscore the need to reevaluate existing vaccination policies in many European countries. At the same time, the pandemic disrupted immunization services, resulting in the largest sustained decline in childhood immunization in 30 years. These challenges called into question issues immunization policies, particularly in certain regions. Countries with effective routine immunization programs generally had successful COVID-19 immunization strategies. In 2019, before the pandemic was declared, an unprecedented number of more than 100 000 measles cases were reported in the WHO European Region. In 2022, an unusually high number of diphteria cases (about 400) were also reported in the region. And the number of antimicrobial resistance genes and the breadth of antimicrobial resistance have increased significantly over the past decade. All this emphasises the need to review immunisation programs regularly and adapt them to changing circumstances.

No universally accepted vaccination policy

While there is no universally accepted vaccination policy to achieve the coverage targets set by national and international guidelines, many European countries are tightening their immunisation policies by enforcing compulsory vaccination. Some governments, such as those in the Nordic countries, have opted for recommended vaccination programmes, maintaining high vaccination coverage and low incidence of vaccine-preventable diseases. Conversely, countries such as France, Italy and Ukraine, have introduced mandatory vaccination programmes in response to declining immunization coverage and increasing outbreaks. During the COVID-19 pandemic, many countries in the WHO European Region used coercive measures to promote immunisation against COVID-19, ranging from the introduction of COVID-19 certificates to the use of fines.

Evidence from a number of European countries, including Italy, France, Latvia, Serbia and Ukraine, shows that the introduction of mandatory childhood immunisation programmes increases vaccine coverage and reduces the incidence of vaccine-preventable diseases compared with the pre-programme scenario. The benefits of introducing childhood routine immunisation mandates outweigh the harms in countries struggling to achieve the desired coverage and reduce the incidence of vaccine-preventable diseases. However, this balance may be different in countries where the recommended immunisation policies maintain adequate coverage without significant challenges.

The case of COVID-19 mandates

Regarding COVID-19 vaccine mandates, studies show that the introduction of COVID-19 certificates was associated with a significant increase in COVID-19 vaccine uptake in Greece, France, Germany, Israel, Italy, Spain and Switzerland. The effect of mandatory vaccination for all or some groups of the population varied from a continuous decrease in the daily doses administered, as in Austria, to no significant effect, to a delayed or temporary increase, as in Italy.

At the same time, there is a risk of some important unintended consequences of introducing compulsory vaccination, including a loss of public confidence in vaccines in general, a decrease in coverage for those vaccines not covered by the mandate, an erosion of individuals' willingness to trust the authorities, and a negative impact on civil liberties. Cases of false vaccination certificates or COVID-19 tests were reported in various European countries, such as Italy, France, Spain and the Netherlands.

Vaccine mandates, a last resort

Despite their positive impact on coverage and disease incidence in routine childhood immunization programmes, the use of vaccine mandates should generally be avoided and considered a last resort. It is advisable to use them as a temporary rather than a permanent tool, and to communicate this to the public. The use of vaccine mandates in public health emergencies, such as the COVID-19 pandemic, is more controversial because it involved the use of new vaccines licensed for emergency use with limited evidence on infection prevention, durability of protection and the need for booster doses.

Incentive-based interventions, such as lotteries and cash payments, have shown promise in increasing vaccine uptake and may be a viable alternative to mandates. It is important to analyse and consider success stories from similar countries, and to emphasise other elements of immunisation policies, such as tailored information campaigns and adequate vaccine supplies. Strengthening the resilience of health systems and increasing funding for primary health care are also essential to support effective immunisation policies. The ultimate goal remains clear: to protect public health while preserving trust and individual freedoms.

Research findings from the PhD project, supervised by Dr. Antoni Trilla and Dr. Elizabeth Diago Navarro, are published in the following papers:

• Effectiveness of COVID-19 Vaccination Mandates and Incentives in Europe
• Effectiveness of Mandatory and Incentive-Based Routine Childhood Immunization Programs in Europe: A Systematic Review of the Literature