Removing conscientious objection: The impact of 'No Jab No Pay' and 'No Jab No Play' vaccine policies in Australia

Dark side of the principles of non-discrimination and proportionality: the case of mandatory vaccination

Deciding the conflict between various rights and interests, especially in medical ethics where health and lives are in question, has significant challenges, and to obtain appropriate outcomes, it is necessary to properly apply the principles of non-discrimination and proportionality. Using the example of mandatory vaccination policies, we show that this task becomes even more difficult when these principles lead us to counterintuitive and paradoxical results. Although the general purpose of these principles is to ensure that decisions and policies seek the highest and broadest possible enjoyment of rights for all (ie, the least restrictive solution), they achieve the complete opposite when applied to mandatory vaccination policies. To highlight and explain these paradoxical results, we present a typology of fifteen hypothetical mandatory vaccination policies containing various degrees of restriction and apply well-established non-discrimination and proportionality tests from constitutional law to each. We argue that mandatory vaccination policies exhibit two characteristics, namely the non-linear relationship between their general purposes and specific goals and the involvement of life and health, suggesting that more restrictive policies should prevail even though less restrictive policies might fail these tests. Using clearly structured and rigorous methodology from constitutional law, the proposed approach delivers a fresh view on the core ethical principles of non-discrimination and proportionality and a potentially useful tool in helping resolve also other challenges encountered in medical ethics beyond mandatory vaccination policies.

The Impact of the No Jab No Play and No Jab No Pay Legislation in Australia: A Scoping Review

Australia has a long history of population-based immunisation programs including legislations. This paper reports on a review of evaluations of the impact of the federal No Jab No Pay (NJNPay) and state implemented No Jab No Play (NJNPlay) legislations on childhood immunisation coverage and related parental attitudes. Five databases were searched for peer-review papers (Medline (Ovid); Scopus; PsycInfo; ProQuest; and CINAHL). Additional searches were conducted in Google Scholar and Informit (Australian databases) for grey literature. Studies were included if they evaluated the impact of the Australian NJNPay and/or NJNPlay legislations. Ten evaluations were included: nine peer-review studies and one government report. Two studies specifically evaluated NJNPlay, five evaluated NJNPay, and three evaluated both legislations. Findings show small but gradual and significant increases in full coverage and increases in catch-up vaccination after the implementation of the legislations. Full coverage was lowest for lower and higher socio-economic groups. Mandates are influential in encouraging vaccination; however, inequities may exist for lower income families who are reliant on financial incentives and the need to enrol their children in early childhood centres. Vaccine refusal and hesitancy was more evident among higher income parents while practical barriers were more likely to impact lower income families. Interventions to address access and vaccine hesitancy will support these legislations.

Vaccine mandates on childcare entry without conscientious objection exemptions: A quasi-experimental panel study

OBJECTIVES

Examine the effect of No Jab No Play policies, which linked vaccine status to childcare service entry without allowing for personal belief exemptions, on immunisation coverage.

STUDY DESIGN

Immunisation coverage rates from the Australian Immunisation Register were linked to regional level covariates from the Australian Bureau of Statistics between January 2016 and December 2019. Differential timings of policy rollouts across states were used to assess changes in coverage with the implementation of policies with generalised linear models. Quantile regression and subgroup analysis were also conducted to explore the variation in policy responses.

RESULTS

Baseline mean vaccination rates in 2016 were 93.4% for one-year-olds, 91.2% for two-year-olds and 93.2% for five-year-olds. Increases in coverage post-policy were significant but small, at around 1% across age groups, with larger increases in two and five-year-olds. Accounting for aggregate time trends and regional characteristics, implementation of the policies was associated with improved full immunisation coverage rates for age one (post-year 1: 0.15% [95 %CI-0.23; 0.52]; post-year 2: 0.56% [95 %CI 0.05; 1.07]), age two (post-year 1: 0.49 [95 %CI: 0.00; 0.97]; post-year 2: 1.15% [95 %CI: 0.53; 1.77], and age five (post-year 1: 0.38% [95 %CI 0.08; 0.67]; post-year 2: 0.71% [95 %CI 0.25; 1.16]. The policy effect was dispersed and insignificant at the lowest quantiles of the distribution of immunisation coverage, and smaller and insignificant in the highest socioeconomic areas.

CONCLUSION

Findings suggest that No Jab No Play policies had a small positive impact on immunisation coverage. This policy effect varied according to prior distribution of coverage and socio-economic status. Childcare access equity and unresponsiveness in high socioeconomic areas remain concerns.

How a generally well-accepted measles vaccine mandate may lead to inequities and decreased vaccine uptake: a preregistered survey study in Germany

Background

In Germany, a measles vaccine mandate came into effect in March 2020, requiring proof of measles immunization for children attending kindergarten or school and for staff in a variety of facilities. Mandates can be successful if implemented with care and in a context-sensitive manner. They may, however, also lead to inequities and decreased uptake of other vaccines. The aim of this study was to investigate the acceptance and potential unintended consequences of the measles vaccine mandate in Germany.

Methods

As part of a larger evaluation project on the new mandate, we conducted an online survey among parents in August/September 2020. We assessed differences in knowledge about the mandate and the measles vaccine by socio-economic status. We used linear and logistic regression to estimate how reactance to the mandate was associated with vaccination status and vaccination intention against other diseases. We used mediation analysis to measure how trust in institutions had an impact on the attitude towards the mandate, mediated by level of reactance.

Results

In total, 4,863 parents participated in the study (64.2% female, mean age = 36.8 years). Of these, 74.1% endorsed a measles vaccine mandate for children. Parents with lower socio-economic status had less knowledge about the mandate and the measles vaccine. The higher parents’ levels of reactance, the lower the vaccination intentions and the likelihood for the child to be vaccinated against other diseases. Furthermore, higher institutional trust decreased the level of reactance and increased positive attitudes towards the mandate (partial mediation).

Conclusions

The new measles vaccine mandate in Germany, though well accepted by many, might have unintended consequences. Parents with lower socio-economic status, who know less about the mandate and vaccine, might be less likely to comply with it. The mandate may also lead to some parents omitting other childhood vaccines, as a way to restore their freedom. This could decrease vaccination coverage of other vaccines. Any potential loss of trust might provoke more reactance and lower acceptance of mandates. Policymakers should now expand communication activities on the mandate, monitor trends in vaccination coverage carefully and take measures to strengthen trust.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14075-y.

Australia's 'No Jab No Play' policies: history, design and rationales

OBJECTIVE

Since 2014, five Australian states have enacted 'No Jab, No Play' policies requiring children to be fully vaccinated to attend childcare and early education services. We review the five policies and their implications for implementers - including healthcare and childcare service providers - and analyse factors that shaped the design of state policies.

METHODS

We employed documentary analysis and analysed key informant interviews in NVivo 12.

RESULTS

Our findings reveal similarities and differences between state provisions regarding exemptions, grace periods, responsibilities of service providers and sanctions for non-compliance. We elaborate on five factors of influence that have shaped No Jab, No Play policies: i) impetus for change; ii) policy normalisation, growing concurrence and stringency; iii) increased co-optation of childcare providers into vaccination governance; iv) policy influence and lessons; and v) partisan politics and the development of party ideologies over time.

CONCLUSION

A range of factors contribute to how and why Australia's NJNPlay policies have taken their current forms.

IMPLICATIONS FOR PUBLIC HEALTH

NJNPlay policies impact families and healthcare providers as part of the broader policy ecosystem concerned with maintaining high immunisation rates in Australia. Increased coercion of parents over time has been tempered by partisan positions on exemptions for disadvantage.

Parental vaccine hesitancy: scope, causes, and potential responses

PURPOSE OF REVIEW

We reviewed the literature about parental vaccine hesitancy, focusing on publications from October 2019 to April 2021 to describe patterns and causes of hesitancy and interventions to address hesitancy.

RECENT FINDINGS

Recent studies expand understanding of the prevalence of vaccine hesitancy globally and highlight associated individual and contextual factors. Common concerns underlying hesitancy include uncertainty about the need for vaccination and questions about vaccine safety and efficacy. Sociodemographic factors associated with parental vaccine hesitancy vary across locations and contexts. Studies about psychology of hesitancy and how parents respond to interventions highlight the role of cognitive biases, personal values, and vaccination as a social contract or norm. Evidence-based strategies to address vaccine hesitancy include presumptive or announcement approaches to vaccine recommendations, motivational interviewing, and use of immunization delivery strategies like standing orders and reminder/recall programs. A smaller number of studies support use of social media and digital applications to improve vaccination intent. Strengthening school vaccine mandates can improve vaccination rates, but policy decisions must consider local context.

SUMMARY

Vaccine hesitancy remains a challenge for child health. Future work must include more interventional studies to address hesitancy and regular global surveillance of parental vaccine hesitancy and vaccine content on social media.

Vaccine sentiments and under-vaccination: Attitudes and behaviour around Measles, Mumps, and Rubella vaccine (MMR) in an Australian cohort

OBJECTIVE

The study aimed to examine the consistency in factors associated with attitudes towards vaccination and MMR vaccination status.

METHODS

Using the nationally representative Longitudinal Study of Australian Children matched with the Australian Childhood Immunisation Register, 4,779 children were included from 2004-2005 to 2010-11. Different MMR vaccine dosages and general attitude towards vaccination were modelled individually with multinomial logit regressions, controlling for demographic, socioeconomic, and health related factors of the children and their primary carers.

RESULTS

The group with non-vaccination and negative attitudes was characterised by more siblings and older parents the group with under-vaccination but positive attitudes was characterised by younger parental age; and the group with under-vaccination and neutral attitudes was characterised by less socioeconomically advantaged areas. The presence of parental medical condition(s), being private or public renters, and higher parental education were associated with under-vaccination but not with attitudes towards vaccination, whilst parental religion was associated with attitudes towards vaccination but not reflected in the vaccine uptake.

CONCLUSIONS

Vaccine attitudes were largely consistent with MRR vaccine outcomes. However, there was variation in the associations of factors with vaccine attitudes and uptake. The results have implications for different policy designs that target subgroups with consistent or inconsistent vaccination attitudes and behaviour. Parents with intentional and unintentional under-vaccination are of policy concern and require different policy solutions.