Public Health

Mandatory vaccination – a bad idea

Mandatory vaccination – a bad idea

This was cropping up quite a lot of late. I was persuaded to write down my thoughts. I did so on twitter, but I have put them here in one place.

There is zero doubt we need to do better in this space. Coverage has slipped, the UK has lost WHO measles free status. In Yorkshire coverage of 2 doses of MMR at age 5 is circa 90%, it should be 95. The 90% masks variability, it is much lower in some cohorts. So we DO need to address this. But mandating vaccination is not a good idea.

Mandating my erode trust in vaccination, which in the UK is reasonably high, after years of work. It wouldn’t take much to significantly erode that trust, and I would fear that mandating would be twisted by some (who have a great deal of influence) to do exactly that.


there  is plenty of evidence to support a view around mandating being a bad plan

There are plenty evidence on this. MacDonald is the best I have seen.  Mandatory infant & childhood immunization: Rationales, issues and knowledge gaps

Key points here

  • Globally, many countries have enacted, strengthened or contemplated mandatory infant and/or childhood immunization.
  • No standard approach to mandatory immunization; varies from soft/flexible to rigid/hard.
  • Varies in terms of vaccines included, age groups covered, penalties, degree of enforcement, and if AEFI compensation.
  • There are ethical, legal and public health implications.
  • Meager evidence on benefits of hard mandatory; may have unintended consequences.
  • Mandatory immunization does not guarantee improved vaccine uptake rate.

Pertinent questions include:

  • Is there a problem with uptake rates? Or is it another problem that is being addressed?
  • Is this the right solution at this time in this context?
  • What components need to be in the mandatory framework (Table 2)?
  • Do these components fit the culture, the context, and the specific problem that the mandatory program is trying to solve at this time?
  • Do other proven strategies need to be part of this change to the immunization program?
  • Will the shift to a mandatory program be accompanied by an increase in resources to the immunization program, and where will those resources come from (i.e., will other public health actions be compromised)?
  • What might be the public response to such a change, especially if choice is restricted, and can this be effectively managed?
  • Is there potential for harm to vulnerable populations? i.e. unintended consequences


see also Cantor writing in NEJM about experience in New York and other US cities, a cautionary tale.



2     what SHOULD we do then

Three broad groups

In my head there are broadly 3 groups

Group 1. The refusers. Probably a small % of the whole. I would wonder whether there is anything much we can do there apart from keep a firm steady sensible line. I fear that going toe to toe here would end in a fierce argument with antivax groups, giving oxygen and may erode trust

Group 2 the hesitant. A simple strategy of building trust with clear and consistent positive messaging. This can and should be done through multiple channels, through human interaction in clinical contexts, though mass media, social media and others.

Group 3. The group that the system misses, slips though net – the strategy here is basically sort the system failures. My sense (and I am happy to be challenged as I don’t know) is that 3 is probably the biggest group. Group 3 there are a group who are not refusing, they are being under-served.

Nationally we have good data to suggest confidence in vaccines is high, PHE do an annual survey on this which indicates this very clearly. Thus the problem we are trying to solve is largely a SYSTEM issue that we need to properly address not a vaccine hesitancy or refuser issue.

Recent national guidance on ‘how to do comms on vaccination’ highlights not giving vaccine deniers more oxygen.

I feel we should be more honest that vaccination is not 100% effective, it’s a science we’re always learning more etc so as to engage in conversation with people’s concerns in more of a humble and less of an authoritarian way. Being authoritarian will play into the arguments of the antivax constituency





3   Vaccine refusal is NOT a disease

Occasionally I have seen “vaccine refusal” being labelled as a disease. This leads me to five massive concerns –

1) disease mongering

2) ist NOT a “disease”. may stigmatize a group of people. not sensible

3) medialises what is a social or system issue

4) might lead to wrong response

5) arguably a “medical response” (term used advisedly) isn’t what needed





4     Strategies for addressing the antivax message

On strategies for combatting antivax narrative which widely circulates on social media, I remain of the view that I am reluctant to go on direct confrontation, it simply gives oxygen to something. Its worth being aware of the tactics and strategies, the recent interest in the concept of firehosing is relevant in this regard. See here applied to antivaxxers, and the RAND report for a wider description with some thought given to counter measures. This recent piece in the BMJ on old and new power was also excellent . three broad lessons which have great relevance to this issue:

Lesson 1: create context, not content New power communities offer real agency to participants create context for people to do so much more than consume depersonalised leaflet can’t compete with distributed, customised messages

Lesson 2: don’t bring a fact to a narrative fight Experts can arm themselves with white papers, peer reviewed studies, and symposia; if these are our only weapons, we will only ever get so far. Experts are increasingly distrusted, the “we know best” mindset is counterproductive. No coincidence that the most effective climate advocacy in the world right now comes from the improvisations and stories of a 16 year old girl rather than the strategic plans of a generations old institution

Lesson 3: not old power v new power; old power + new power Dont despair at, criticise, and wish away the antivaccination movement.  Learn new tactics


It’s not about fighting misinformation with “more or better evidence”, there is a clash of strategies and tactics; combined with different stakeholders ability / willingness to get the nuances in studies + different understandings of “what counts” as evidence. The strategies suggested by RAND on countermeasures are excellent.

This is nuanced stuff and needs a nuanced response from people highly skilled in such strategies




5     Final thoughts

There MAY be merits, personally I don’t buy it

But BEFORE we go to mandation we ought to make sure we have fully exhausted higher order (and more evidence based) strategies. It might also be necessary to think through enforceability and sanction (and consequences of sanction) of such strategies, would there be exceptions? What are the consequences for broader issues around informed consent and relationship between clinicians and parents.


I should be clear I am writing here as a Director of Public Health in a British context. I know these issues will have nuances across the world, that underscores the need for nuanced approaches led by local evidence and skilled individuals.




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