The UK has had a comprehensive vaccination programme in place for some decades, and uptake data of in excess of 90% for the childhood programme in 2017–2018 (NHS Digital, 2019) has made this a highly successful intervention in the prevention of ill-health. However, a small but concerning decline in uptake has been observed recently, and earlier this year, the UK lost its measles-free status. The World Health Organization (WHO) determined that the UK could no longer be considered as having ‘eliminated’ measles because transmission had been re-established.
Does mandatory vaccination improve uptake?
This rise in measles cases, coupled with Health and Social Care Secretary Matt Hancock's refusal to rule out mandatory vaccination, has initiated the debate around the use of such punitive measures as a response to the problem. Adopting legislative methods may seem to be a straightforward approach, and many other countries have already done this, yet placing a mandate on vaccination in the UK requires careful deliberation.
The initial consideration must be whether mandating vaccination actually leads to an increase in vaccination uptake—and it would seem that this is not necessarily the case. In the US where vaccination with measles, mumps and rubella (MMR) is compulsory, data from 2016 show a coverage rate of 91.1% for children between 19–35 months old (Centers for Disease Control and Prevention, 2017), whereas in the England, in the same time period, uptake of 91.9% was achieved (NHS Digital, 2019). Furthermore, other European countries have achieved measles elimination without the need to mandate vaccination (WHO, 2019).
Adopting the mandatory vaccination approach in the UK would present some serious logistical challenges
Increasing the inequality gap
In places where vaccination is compulsory, the use of disincentives such as restricting school entry, issuing fines and withholding financial benefits are used as a way to encourage vaccination. Yet, this could be viewed as unfairly disadvantaging children based on their parents’ beliefs; it may even increase the inequality gap leaving the less well-off disproportionally affected. This action also assumes that parents do not vaccinate their children through choice, and does not consider those who may have genuine difficulties in accessing services. Additionally, there would be challenges in monitoring this and there will always be individuals who have reason to be exempt from inclusion; how would these be determined?
Alienating parents
From a philosophical standpoint, enforcing immunisation takes a utilitarian view that it would maxi it would maximise the desired outcome of increasing MMR uptake and eliminating disease in the population. However, this may result in alienating parents; those working on the frontline delivering vaccination messages do so having developed trusting relationships with parents, and this could be threatened by removing individual choice.
Despite media attention around the anti-vaccination movement, tracking surveys reveal a high level of satisfaction with the vaccination programme in England (Campbell et al, 2017), suggesting that mandating vaccination is unnecessary.
Only a very small proportion of parents are completely against immunisation so it makes sense to focus efforts and resources on exploring the reasons why some are not accessing the services available to them, and it is difficult to imagine how making vaccination compulsory would be a solution for this.
‘Some countries have mandated vaccination in attempts to achieve this, yet there is little evidence to suggest that this approach is effective.’
Combined effort
Reclaiming and maintaining the vaccination coverage rate required to keep the population safe from disease and for the UK to retrieve its measles-free status, will always require a combined effort and commitment from those involved with the programme. Some countries have mandated vaccination in attempts to achieve this, yet there is little evidence to suggest that this approach is effective.
Adopting this approach in the UK would present some serious logistical challenges, as well as compromising the relationship between parents and their healthcare provider by eliminating parental autonomy.