Lewis First, MD, MS, Editor in Chief, Pediatrics
January 16, 2020
We focus a lot of attention on articles that deal with ways to increase vaccination rates in the United States. We do so because our vaccine rates are suboptimal for a variety of reasons, many of which are related to unsubstantiated risk. What can we do to improve vaccination rates? Europe may offer us an answer. Did you know for example that there are 7 countries in Europe that mandate vaccination and only 2 of these allow nonmedical exemptions? In addition, 6 of these 7 countries will inflict financial penalties to families who do not immunize their children. So what are the vaccination rates in these countries and what about the incidence of vaccine-preventable diseases like pertussis and measles?
Vaz et al (10.1542/peds.2019-0620) evaluated these questions in new study being early released in our journal. The authors used data from the European Centers for Disease Control and Prevention and the World Health Organization to look at European countries that do and do not mandate vaccine administration to children in regard to vaccination against measles and pertussis, as well as the annual incidence of these two diseases in these countries. The results are interesting and perhaps not exactly what you might expect. On the good side, mandatory vaccinations did result in statistically significant increases in childhood vaccination against pertussis and measles. The interesting news is that only when a country did not allow nonmedical exemptions did the mandatory vaccine policy result in a significant decrease in measles, but not for pertussis. Why?
We asked Drs. Sean O’Leary (University of Colorado) and Yvonne Maldonado (Stanford) (10.1542/peds.2019-2436) to weigh in with an accompanying commentary. They draw some interesting lessons about vaccination mandates and changes in disease burden and bring to light other important considerations related to financial penalties and vaccination mandates. One important takeaway is that vaccine policies are uniform across each specific European country instead of the patchwork that exists across states. There is a lot of great information injected into the pages of this important study—so take a shot at reading both this study and commentary and then share with parents who will hopefully be even more convinced about why vaccination should be mandatory for their child. If state legislators read this study and commentary, perhaps vaccination policy, including mandates, will be made stronger.
Copyright © 2020 American Academy of Pediatrics
Mandatory Vaccination in Europe and Epidemiology of Vaccine Preventable Diseases
https://pediatrics.aappublications.org/content/145/2/e20190620?utm_source=TrendMD&utm_medium=TrendMD&utm_campaign=Pediatrics_TrendMD_0
VIDEO
https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/appi.ajp.2020.20030272
Vaccination Policies and Disease Incidence Across the Pond: Implications for the United State
Abbreviation:CI — confidence interval
In this issue of Pediatrics, Vaz et al report the results of their study, “Mandatory Vaccination in Europe."1 Although this study analyzed vaccination and vaccine-preventable disease trends in Europe, the policy implications are timely and relevant to US vaccination practices given the ongoing measles outbreaks in the United States and the legislative responses playing out in state capitols across the United States.
In this study, the authors examined the associations between vaccination mandate policies and subsequent vaccination coverage and measles and pertussis incidence in 29 European countries. Stated another way, the authors wanted to know if having a stricter vaccination policy resulted in higher vaccination rates and a lower incidence of 2 highly contagious vaccine-preventable diseases.
We already know that in the United States, a stricter state-based vaccination policy leads to lower rates of nonmedical exemptions2,3 and lower rates of vaccine-preventable diseases,4,5 but before the study by Vaz et al,1 these questions had not been examined among European countries. We can think of 3 main reasons this study is highly relevant to US vaccine policy: First, it demonstrates that the impact of such policies is not country specific, offering guidance to countries throughout the world on strategies to increase or maintain high vaccination rates. Second, some of the policies used in Europe are strategies that have not been tried previously in the United States and may offer US policy makers strategies to consider. Third, and most important, vaccine-preventable diseases are a worldwide problem; they know no borders, and therefore, it is in the interest of all of us to study and understand how to best achieve high vaccination coverage throughout the world. Indeed, many US measles outbreaks in the last decade have been a result of cases imported from Europe, (most recently and visibly, the Clark County outbreak in Washington state).6
To examine these questions, the authors used data from the European Centre for Disease Prevention and Control and the World Health Organization to examine the relationship between country-level vaccination policies and measles and pertussis vaccination coverage and the annual incidence of these diseases in 29 European countries. To try to assess the specific impact of the vaccination policies, the authors used regression models to examine these associations, adjusting for numerous country-level covariates likely to have an impact on vaccination coverage or disease incidence, such as education, urbanicity, income, and age of the population.
The authors found that mandatory vaccination was associated with 3.00 percentage points higher prevalence of measles vaccination (95% confidence interval [CI], 0.35–5.64) and 2.14 percentage points higher prevalence of pertussis vaccination (95% CI, 0.13–4.15) compared with countries that did not have mandatory vaccination. Mandatory vaccination was associated with decreased measles incidence in countries that did not allow nonmedical exemptions (adjusted incident rate ratio = 0.14; 95% CI, 0.05–0.36), although there was no significant association between mandatory vaccination and pertussis incidence. The authors also found that incorporating financial penalties for not vaccinating increased vaccination uptake. In countries with such policies, every €500 increase in the maximum possible penalty was associated with an increase of 0.8 percentage points for measles vaccination coverage (95% CI, 0.50–1.15; P ≤ .0001) and an increase of 1.1 percentage points for pertussis vaccination coverage (95% CI, 0.95–1.30; P ≤ .0001).
In Europe and other parts of the world, policy makers have (to varying degrees) employed financial penalties for parents who choose not to vaccinate. Policy makers in the United States have for the most part shied away from such policies. This study should make us reconsider this approach because it appears to be effective. In Hungary, for example, parents could face a financial penalty of up to ∼€1600 (∼$1800) if they fail to comply with vaccination requirements; this has resulted in high vaccination coverage and essentially no measles or pertussis cases. Importantly, these types of financial penalties may also be fair because it is clear that persons unvaccinated by parental choice place an unneeded financial burden on our health care system.7–9
Sean T. O’Leary and Yvonne A. Maldonado
Pediatrics February 2020, 145 (2) e20192436;
Pediatrics February 2020, 145 (2) e20192436;
Abbreviation:CI — confidence interval
In this issue of Pediatrics, Vaz et al report the results of their study, “Mandatory Vaccination in Europe."1 Although this study analyzed vaccination and vaccine-preventable disease trends in Europe, the policy implications are timely and relevant to US vaccination practices given the ongoing measles outbreaks in the United States and the legislative responses playing out in state capitols across the United States.
In this study, the authors examined the associations between vaccination mandate policies and subsequent vaccination coverage and measles and pertussis incidence in 29 European countries. Stated another way, the authors wanted to know if having a stricter vaccination policy resulted in higher vaccination rates and a lower incidence of 2 highly contagious vaccine-preventable diseases.
We already know that in the United States, a stricter state-based vaccination policy leads to lower rates of nonmedical exemptions2,3 and lower rates of vaccine-preventable diseases,4,5 but before the study by Vaz et al,1 these questions had not been examined among European countries. We can think of 3 main reasons this study is highly relevant to US vaccine policy: First, it demonstrates that the impact of such policies is not country specific, offering guidance to countries throughout the world on strategies to increase or maintain high vaccination rates. Second, some of the policies used in Europe are strategies that have not been tried previously in the United States and may offer US policy makers strategies to consider. Third, and most important, vaccine-preventable diseases are a worldwide problem; they know no borders, and therefore, it is in the interest of all of us to study and understand how to best achieve high vaccination coverage throughout the world. Indeed, many US measles outbreaks in the last decade have been a result of cases imported from Europe, (most recently and visibly, the Clark County outbreak in Washington state).6
To examine these questions, the authors used data from the European Centre for Disease Prevention and Control and the World Health Organization to examine the relationship between country-level vaccination policies and measles and pertussis vaccination coverage and the annual incidence of these diseases in 29 European countries. To try to assess the specific impact of the vaccination policies, the authors used regression models to examine these associations, adjusting for numerous country-level covariates likely to have an impact on vaccination coverage or disease incidence, such as education, urbanicity, income, and age of the population.
The authors found that mandatory vaccination was associated with 3.00 percentage points higher prevalence of measles vaccination (95% confidence interval [CI], 0.35–5.64) and 2.14 percentage points higher prevalence of pertussis vaccination (95% CI, 0.13–4.15) compared with countries that did not have mandatory vaccination. Mandatory vaccination was associated with decreased measles incidence in countries that did not allow nonmedical exemptions (adjusted incident rate ratio = 0.14; 95% CI, 0.05–0.36), although there was no significant association between mandatory vaccination and pertussis incidence. The authors also found that incorporating financial penalties for not vaccinating increased vaccination uptake. In countries with such policies, every €500 increase in the maximum possible penalty was associated with an increase of 0.8 percentage points for measles vaccination coverage (95% CI, 0.50–1.15; P ≤ .0001) and an increase of 1.1 percentage points for pertussis vaccination coverage (95% CI, 0.95–1.30; P ≤ .0001).
In Europe and other parts of the world, policy makers have (to varying degrees) employed financial penalties for parents who choose not to vaccinate. Policy makers in the United States have for the most part shied away from such policies. This study should make us reconsider this approach because it appears to be effective. In Hungary, for example, parents could face a financial penalty of up to ∼€1600 (∼$1800) if they fail to comply with vaccination requirements; this has resulted in high vaccination coverage and essentially no measles or pertussis cases. Importantly, these types of financial penalties may also be fair because it is clear that persons unvaccinated by parental choice place an unneeded financial burden on our health care system.7–9
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