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Pediatrics. 2020 Feb;145(2). pii: e20190620. doi: 10.1542/peds.2019-0620. Epub 2020 Jan 13.

Mandatory Vaccination in Europe.

Author information

Departments of Epidemiology and.
Hubert Department of Global Health, Rollins School of Public Health,
Biostatistics and Bioinformatics.
Hospital Clínic, Barcelona Institute for Global Health, Universitat de Barcelona, Barcelona, Spain.
Hubert Department of Global Health, Rollins School of Public Health.
Emory Vaccine Center, and.
Winship Cancer Institute, Emory University, Atlanta, Georgia; and.
Department of Pediatrics, School of Medicine.



Mandatory vaccination has been effective in maintaining high vaccination coverage in countries such as the United States. However, there are no peer-reviewed analyses of the association between mandates and both coverage and subsequent incidence of vaccine-preventable disease in Europe.


Using data from the European Centre for Disease Prevention and Control and the World Health Organization, we evaluated the relationship between country-level mandatory vaccination policies and (1) measles and pertussis vaccine coverage and (2) the annual incidence of these diseases in 29 European countries. Multivariate negative binomial and linear regression models were used to quantify these associations.


Mandatory vaccination was associated with a 3.71 (95% confidence interval [CI]: 1.68 to 5.74) percentage point higher prevalence of measles vaccination and a 2.14 (95% CI: 0.13 to 4.15) percentage point higher prevalence of pertussis vaccination when compared with countries that did not have mandatory vaccination. Mandatory vaccination was only associated with decreased measles incidence for countries without nonmedical exemptions (adjusted incidence rate ratio = 0.14; 95% CI: 0.05 to 0.36). We did not find a significant association between mandatory vaccination and pertussis incidence.


Mandatory vaccination and the magnitude of fines were associated with higher vaccination coverage. Moreover, mandatory vaccination was associated with lower measles incidence for countries with mandatory vaccination without nonmedical exemptions. These findings can inform legislative policies aimed at increasing vaccination coverage.

Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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