Vaccine mandates

What are vaccine mandates?

Vaccine mandates are a way to compel people to get vaccinations. This could mean fining people who do not comply or excluding them from certain activities and locations, like hospitality venues or workplaces.

Several countries have introduced mandates of some type for Covid vaccines. But they are controversial, with some public health experts arguing education and persuasion should be preferred to compulsion wherever possible.

Covid passports have emerged as one way of proving Covid vaccine status but are not in themselves a vaccine mandate, particularly when testing is included as an alternative.

Does the UK have Covid vaccine mandates?

In general, UK politicians have argued against widespread vaccine mandate schemes often on the grounds of liberty. The UK also already has very high levels of vaccine confidence comparatively, which has led some to argue a mandate is unnecessary.

The UK government did, however, amend the Health and Social Care Act 2008 to mandate Covid vaccination for healthcare workers. Care home workers (unless exempt) have been required to have two doses of an approved Covid vaccine since November 2021, with the option to redeploy unvaccinated workers into non-frontline roles or put them on unpaid leave until they receive both doses. This was revoked on 15 March 2022.

The mandate was also supposed to be extended to frontline health and social care workers, including staff like porters and receptionists who might have contact with patients, from April 2022.

However, on 31 January 2022, a few days before healthcare staff were required to have had their first vaccination, the health secretary, Sajid Javid, announced that subject to a consultation and parliamentary approval the mandate would be revoked. The government suggested this was due to the fact that the emergence of the slightly milder Omicron variant and more people being infected meant that the risk of hospital admission had declined, and two doses of a vaccine were no longer as effective.^[1]

Mandates are not in place in Scotland, Wales or Northern Ireland.^[2]

Are other countries using Covid-19 vaccine mandates?

Yes, several countries have now introduced vaccine mandates, although generally with exemptions for those who cannot be vaccinated.

Austria’s vaccine mandate came into force on 3 February with unvaccinated over-18s who are not exempt facing fines of up to €3,600 every three months. However, enforcement was not due to begin until mid-March 2022, and in early March the Austrian government announced that the law would be suspended for three months.^[3] A similar proposed mandate is still being discussed in Germany.^[4]

Debate on Germany’s similar planned mandate has been pushed back, however, and it is unclear when it might be introduced.^[5]

Other countries have introduced partial mandates, either for specific age or workforce groups. Italy, which had originally introduced mandatory vaccination for healthcare workers in April 2021, for example, extended this to all school staff, police and the military in December 2021, and then in January 2022 to all those aged 50 and over, with those in work facing possible suspension without pay if they refuse to be vaccinated.^[6] Its Covid pass will start to be rolled back from April although the mandate for over-50s will be maintained until June.^[7]

Greece has also approved mandatory vaccination for over-60s, with a monthly €100 fine added to tax bills for those who refuse, although people who have recently recovered are exempt.^[8]

France has had mandatory vaccination for healthcare workers since October 2021, while New Zealand introduced a requirement for various public sector workers.^[9] The US government has mandated that federal employees be vaccinated unless exempt since November 2021 but an attempt to mandate that workers at private companies with more than 100 employees be fully vaccinated or tested weekly was blocked by the Supreme Court. Individual states have taken their own approaches with some introducing mandates for employees but others banning or blocking vaccine mandates.^[10]

What are the potential benefits of vaccine mandates?

Vaccine mandates aim to increase the level and/or speed of vaccination programs by incentivising people to come forward to be vaccinated, increasing the level of protection against a disease in the population. The arguments for them are generally strongest in countries where vaccine confidence is lower or when countries are facing a surge in infections and significant pressure on healthcare provision.

In some cases, evidence suggests that vaccine mandates have increased take-up. Vaccine coverage increased in France, Italy and Germany in recent years after they introduced or extended vaccine mandates for various childhood diseases, for example.

But this is not always the case. Ukraine had to end its mandatory measles and rubella campaign in 2006 after negative media response and controversy about alleged side-effects. One study comparing different countries’ approaches found no correlation between mandates and rates of childhood vaccination in the EU.^[11]

Effects could also be different for Covid vaccination, with vaccine hesitancy driven in part by concerns about rapid development and long-term safety.^[12] Outcomes are also context-dependent; one recent study of Covid passports suggested that they increased vaccination uptake in the short term but not in countries which already had high uptake.^[13]

What are the potential problems?

Vaccine mandates raise ethical questions; some consider them an unacceptable infringement of individual liberty regardless of potential public health benefits. Where vaccine hesitancy varies between different groups there is also the risk that vaccine mandates could exacerbate existing inequalities.^[14]

There are concerns around whether mandates might reduce public trust in government, undermining support for vaccination and other public health measures and proving counterproductive in the long term.^[15] Ukraine’s experience shows that public response to mandates can be an issue, and there have reportedly been some protests in response to recent attempts to introduce Covid vaccine mandates. France postponed implementing a vaccine mandate for health workers in Martinique and Guadeloupe after protests. Effective enforcement could also be difficult.^[16]

When it comes to mandates on healthcare workers there is also the potential impact on healthcare provision if a signification number of staff refuse to be vaccinated. However, it is still unclear how much of an issue this will be. Although unions and providers in the UK have warned that there could be a major impact on staffing in some areas, the French health minister stated in October 2021 that only 0.6% of healthcare staff were still unvaccinated and could be suspended after France brought in its mandate.^[17]

The World Health Organization has argued that vaccine mandates could be a proportionate policy response, but should be a last resort, used only if other policy interventions, like public education, have failed, and where they would have unequivocal public health benefits.^[18] Jeremy Farrar, Director of Wellcome Trust, similarly argued at a recent Institute for Government event for example: “…the UK has had such remarkable vaccine uptake compared to essentially every other country because prior to the pandemic the UK actually had very good high levels of population trust in vaccines… in the UK we would be much better advised to explain…. [and] use the systems we have in place and persuade people rather than coerce people”.

To determine whether vaccine mandates could be a proportionate policy response in the UK the government might need to consider how much pressure Covid was putting on healthcare services at the time, the number of people vaccinated, the likely impact in terms of increasing uptake, the level of pre-existing immunity (from infection as well as vaccination), vaccine supply and efficacy, and the success or otherwise of other attempts to incentivise vaccination.^[19]

Are vaccine mandates a new idea?

Vaccine mandates have been used by governments since the 18th century. Smallpox vaccination was made compulsory for infants in England and Wales in 1853, provoking some resistance. Exemption on grounds of conscientious objection was introduced in 1898 and made easier to access in 1907, which was followed by a fall in vaccination rates. The Vaccination Acts were repealed by the National Health Service Acts in 1946 and 1947, in part for administrative reasons but also because a model focused on education and persuasion rather than compulsion for diphtheria vaccination had proved successful.^[20]

Vaccine mandates have also been used more recently. Several European countries introduced or extended vaccine mandates in recent years in response to disease outbreaks. France, for example, made 11 childhood vaccines mandatory in 2017, with fines and possible prison sentences for non-compliance.^[21]

While vaccine mandates have been around a long time, they have more often been used in relation to childhood vaccinations – their use for adults has expanded during the Covid pandemic.

Are vaccine mandates likely to be used more widely in the UK in future?

The UK government had introduced vaccine mandates for care home workers and was planning to introduce them for other healthcare workers but has now reversed that decision and revoked the requirement for care home workers. It also backed away from imposing a vaccine mandate for access to some venues when it decided to allow testing to be included in its Plan B Covid passport scheme.

However, it has suggested that the decision to reverse mandatory vaccination for healthcare workers is down to the reduced severity of, and vaccine effectiveness against, the new Omicron variant. This leaves open the possibility that mandates could be revived if a more virulent variant emerged, though any such revival would likely be controversial.

1. House of Commons, Hansard, ‘Vaccination: Condition of Deployment', Volume 708: debated on Monday 31 January 2022, https://hansard.parliament.uk/commons/2022-01-31/debates/C23A5791-2CC9-44FA-B9D6-BC9355C014C1/VaccinationConditionOfDeployment; Department of Health and Social Care, Coronavirus (COVID-19) vaccination of people working or deployed in care homes: operational guidance, www.gov.uk/government/publications/vaccination-of-people-working-or-deployed-in-care-homes-operational-guidance/coronavirus-covid-19-vaccination-of-people-working-or-deployed-in-care-homes-operational-guidance; Department of Health and Social Care, 'Consultation on removing vaccination as a condition of deployment for health and social care staff', press release, 31 January 2022, www.gov.uk/government/news/consultation-on-removing-vaccination-as-a-condition-of-deployment-for-health-and-social-care-staff; Campbell D, Ministers plan to scrap vaccine mandate for NHS staff in England, The Guardian, 31 January 2022, www.theguardian.com/society/2022/jan/31/ministers-plan-to-scrap-vaccine-mandate-for-nhs-staff-in-england
2. British Medical Association, COVID-19: mandatory vaccine guidance, www.bma.org.uk/advice-and-support/covid-19/vaccines/covid-19-mandatory-vaccine-guidance
3. Jones S, Austrian parliament approves compulsory Covid vaccination law, Financial Times, 20 January 2022, www.ft.com/content/3fc94e2e-c954-49b5-bc74-58231f276c7e; Jones S, Austria drops compulsory Covid vaccine mandate, Financial Times, 9 March 2022, www.ft.com/content/65650cbe-10b0-4350-8eb5-691624be8c2d
4. Chazan G and Solomon E, Germany moves towards mandatory vaccination and tightens Covid curbs, Financial Times, 2 December 2021, www.ft.com/content/8fae9488-a66a-4cf3-ba48-49928ceea7f6; The Independent, Germany mulls COVID-19 vaccine mandate, easing restrictions, 17 March 2022, www.independent.co.uk/news/germany-ap-covid-berlin-robert-koch-institute-b2037922.html?r=22217
5. Chazan G and Solomon E, Germany moves towards mandatory vaccination and tightens Covid curbs, Financial Times, 2 December 2021, www.ft.com/content/8fae9488-a66a-4cf3-ba48-49928ceea7f6; Landler M, Vaccine Mandates Rekindle Fierce Debate Over Civil Liberties, The New York Times, 10 December 2021, www.nytimes.com/2021/12/10/world/europe/vaccine-mandates-civil-liberties.html; Von Der Burchard H, Olaf Scholz under fire after dodging decision on COVID vaccine mandate, Politico, 13 January 2022, www.politico.eu/article/olaf-scholz-fire-dodge-covid-vaccine-mandate
6. Paterlini M, Covid-19: Italy makes vaccination mandatory for healthcare workers, The BMJ, 6 April 2021, www.bmj.com/content/373/bmj.n905; Amante A and Jones G, Italy tightens screws on COVID unvaccinated, extends shot mandate, Reuters, 24 November 2021, www.reuters.com/world/europe/italy-restrict-access-unvaccinated-indoor-venues-sources-2021-11-24; Roberts H, Italy makes vaccines mandatory for over-50s, Politico, 5 January 2022, www.politico.eu/article/italy-coronavirus-vaccine-mandatory-over-50-omicron
7. Paterlini M, Covid-19: Italy makes vaccination mandatory for healthcare workers, The BMJ, 6 April 2021, www.bmj.com/content/373/bmj.n905; Amante A and Jones G, Italy tightens screws on COVID unvaccinated, extends shot mandate, Reuters, 24 November 2021, www.reuters.com/world/europe/italy-restrict-access-unvaccinated-indoor-venues-sources-2021-11-24; Roberts H, Italy makes vaccines mandatory for over-50s, Politico, 5 January 2022, www.politico.eu/article/italy-coronavirus-vaccine-mandatory-over-50-omicron; Albanse C and Speciale A, Draghi Sets Italy’s Exit From Covid Rules in European Reopening, Bloomberg, 17 March 2022, www.bloomberg.com/news/articles/2022-03-17/italy-set-to-scrap-most-covid-rules-as-emergency-period-ends
8. The Independent, Greece approves mandatory vaccination for those aged over 60, 1 December 2021, www.independent.co.uk/news/greece-parties-kyriakos-mitsotakis-athens-b1968058.html
9. www.service-public.fr/particuliers/actualites/A15106; Reuters, New Zealand makes COVID-19 vaccinations mandatory for health workers, 11 October 2021, www.reuters.com/world/asia-pacific/new-zealand-reports-fall-local-covid-19-cases-all-auckland-2021-10-11
10. The White House, Update on Implementation of COVID-⁠19 Vaccination Requirement for Federal Employees, 24 November 2021, www.whitehouse.gov/omb/briefing-room/2021/11/24/update-on-implementation-of-covid-19-vaccination-requirement-for-federal-employees; Palma S, US Supreme Court halts Joe Biden’s Covid vaccine mandate for employers, Financial Times, 13 January 2022, www.ft.com/content/9ff31d53-2c5a-4e82-8fab-22fbf85cb66c; Sherman N, US Supreme Court blocks Biden's workplace vaccine mandate, BBC News, 14 January 2021, www.bbc.co.uk/news/world-us-canada-59989476
11. Vanderslott S, Greece to make COVID vaccines mandatory for over-60s, but do vaccine mandates work?, The Conversation, 1 December 2021, https://theconversation.com/greece-to-make-covid-vaccines-mandatory-for-over-60s-but-do-vaccine-mandates-work-172672; www.ncbi.nlm.nih.gov/pmc/articles/PMC6607737; www.ncbi.nlm.nih.gov/pmc/articles/PMC6607743; Asset project, Compulsory vaccina0on and rates of coverage immunisation in Europe, www.asset-scienceinsociety.eu/reports/page1.html
12. Savulescu J, Wilkinson D and Pugh J, Why the UK shouldn’t introduce mandatory COVID vaccination, The Conversation, 6 December 2021, https://theconversation.com/why-the-uk-shouldnt-introduce-mandatory-covid-vaccination-173179
13. Mills M and Rüttenauer T, The impact of mandatory COVID-19 certificates on vaccine uptake: Synthetic Control Modelling of Six Countries, Leverhulme Centre for Demographic Science and Nuffield College, 1 New Road, Oxford, OX1 1NF, University of Oxford, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1027643/S1401_University_of_Oxford_and_Nuffield_College_The_impact_of_mandatory_COVID-19_certificates_on_vaccine_uptake_Synthetic_Control_Modelling_of_Six_Countries__14_October_2021.pdf
14. https://apps.who.int/iris/rest/bitstreams/1342697/retrieve
15. Ibid.
16. Vanderslott S, Greece to make COVID vaccines mandatory for over-60s, but do vaccine mandates work?, The Conversation, 1 December 2021, https://theconversation.com/greece-to-make-covid-vaccines-mandatory-for-over-60s-but-do-vaccine-mandates-work-172672; The Guardian, Tens of thousands protest against compulsory Covid jabs in Austria, 11 December 2021, www.theguardian.com/world/2021/dec/11/tens-of-thousands-protest-against-compulsory-covid-jabs-in-austria; Al Jazeera, Protesters against vaccine mandate in Belgium clash with police, 5 December 2021, www.aljazeera.com/news/2021/12/5/protesters-against-vaccine-mandate-in-belgium-clash-with-police; France24,France postpones vaccine mandate after violent unrest in Martinique and Guadeloupe, 26 November 2021, www.france24.com/en/europe/20211126-france-postpones-vaccine-mandate-after-violent-unrest-in-martinique-and-guadeloupe; Kirshbaum E, Violence in Germany as thousands protest against vaccine mandates, The Independent, 4 January 2022, www.independent.co.uk/news/world/europe/covid-lockdown-protests-vaccine-germany-b1986421.html; Henley J and Oltermann P, Vaccine mandates, fines, gym bans: how Europe hopes to persuade unjabbed, The Guardian, 6 January 2022, www.theguardian.com/society/2022/jan/06/vaccine-mandates-fines-gym-bans-how-europe-hopes-to-persuade-unjabbed
17. Department of Health and Social Care, Making vaccination a condition of deployment in health and wider social care sector: Government response to public consultation, 9 November 2021, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1032203/making-vaccination-a-condition-of-deployment-in-the-health-and-wider-social-care-sector-government-response.pdf; Campbell D, England hospital units may close as staff revolt over jab mandate, says NHS leader, The Guardian, 20 December 2021, www.theguardian.com/society/2021/dec/20/england-hospital-units-may-close-as-staff-revolt-over-jab-mandate-says-nhs-leader; The BMJ, Compulsory covid vaccination: Loss of care home workers puts beds and care at risk, warn unions and providers, 21 September 2021, www.bmj.com/content/374/bmj.n2318; France Info, Covid-19 : "Aux alentours de 15 000" soignants ne se sont pas fait vacciner, estime Olivier Véran, 13 October 2021, www.francetvinfo.fr/sante/maladie/coronavirus/video-covid-19-aux-alentours-de-15-000-soignants-ne-se-sont-pas-fait-vacciner-estime-olivier-veran_4805641.html; The BMJ, Covid-19 vaccination should be mandatory for healthcare workers, 2 November 2021, www.bmj.com/content/375/bmj.n2670 
18. United Nations Regional Information Centre for Western Europe, WHO: Mandatory vaccinations are a last resort, 7 December 2021,https://unric.org/en/who-mandatory-vaccinations-are-a-last-resort; https://apps.who.int/iris/rest/bitstreams/1342697/retrieve
19. https://apps.who.int/iris/rest/bitstreams/1342697/retrieve; Savulescu J, Wilkinson D and Pugh J, Why the UK shouldn’t introduce mandatory COVID vaccination, The Conversation, 6 December 2021, https://theconversation.com/why-the-uk-shouldnt-introduce-mandatory-covid-vaccination-173179; Davis N, Do Covid vaccine mandates work?, The Guardian, 3 December 2021, www.theguardian.com/world/2021/dec/03/do-covid-vaccine-mandates-work
20. Millward G, 'Chapter 2: Smallpox' in Vaccinating Britain: Mass vaccination and the public since the Second World War, 2019, www.ncbi.nlm.nih.gov/books/NBK545998
21. Ro C, Why mandatory vaccination is nothing new, BBC Future, 1 November 2021, www.bbc.com/future/article/20211029-why-mandatory-vaccination-is-nothing-new; Vanderslott S, Greece to make COVID vaccines mandatory for over-60s, but do vaccine mandates work?, The Conversation, 1 December 2021, https://theconversation.com/greece-to-make-covid-vaccines-mandatory-for-over-60s-but-do-vaccine-mandates-work-172672