Overall, we found that the occurrence of recent outbreaks is a major factor in the introduction of mandatory vaccination, particularly for high and upper-middle-income countries in Europe. Germany, for example, made measles vaccination mandatory for school and day-care attendance in 2020 following large outbreaks.6 Similarly, Serbia tightened mandatory vaccination laws following a measles outbreak in 2014 to 2015 by introducing harsher penalties.7 Trends of reported cases of measles can be explored in detail here.

Secondly, many low- and lower-middle-income countries have resorted to mandatory vaccination policies because of a lack of other policy options. Nonetheless, many have still missed their target vaccination rates due to problems with vaccine supply, delivery, and access. In Guyana for example, vaccination is mandatory, yet vaccination coverage is hindered by the management of the supply chain in keeping storage temperatures consistent and the distribution of freeze-sensitive vaccines.8 In Nigeria, vaccination is mandatory, and several states have enacted legislation criminalising vaccine refusal. Yet as Onyemelukwe (2016) argues, there are structural, logistical, political, systemic, religious and cultural obstacles to the effective distribution and uptake of vaccines, ranging from cold chain issues, to corruption and security issues.9 There is thus often variation between vaccination in policy compared to in practice.

These findings will be useful to inform policymakers considering the merits of mandatory vaccination:

1) In the past, an outbreak of a disease (such as measles) has led to introduction of mandatory vaccines even in countries where previously all vaccinations were recommended;

2) Making a vaccine mandatory should not be the only policy tool but needs to be combined with strong access and availability of vaccines;

3) It is not just a matter of whether to mandate a vaccine, but how this mandate will be enforced, whether people will comply, and the impact on state-citizen relations.  

In summary, mandatory vaccination must be considered with caution. A country’s past experience with mandates, vaccination services, ability for enforcement, public attitudes, and the current state of disease outbreaks will all play a part in whether mandatory vaccination should be introduced.

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