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Mapping the Global Adoption of Mandatory Vaccination against COVID-19 Pandemic: A Scoping Review
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25 July 2023
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Abstract
Coronavirus (COVID-19) pandemic caused sicknesses ranging from mild to deadly, which disrupted lives and healthcare systems across the globe. Despite the availability of vaccines that are effective in significantly reducing the risks of death and severe dis-ease, misperceptions of COVID-19 vaccine safety, efficacy, risks, and mistrust in insti-tutions responsible for vaccination campaigns have been reported as factors contrib-uting to vaccine hesitancy, making vaccination rate not satisfactory, which resulted in some countries implementing mandatory covid-19 vaccination to increase vaccine up-take. This scoping review aimed at mapping global countries that have adopted the mandatory covid-19 vaccination and the reaction of citizens. PRISMA Extension for Scoping Reviews was used. Google Scholar was used to identify papers published in English from December 2019 to February 2022, irrespective of their methodology. One hundred forty studies were identified. After screening for duplication, access, and rel-evance, 24 were eligible for review. About eleven countries implemented mandatory vaccination, mostly among health workers. Citizens’ reactions towards the policy var-ied, with some in support of the policy but with a preference for the healthcare workers, and some in support but with the condition that it will only apply to travel, schools, and shopping areas, while others rejected the policy. Studies that may be relevant but were excluded due to eligibility criteria may be a limiting factor to this study. Several ethical considerations should be explicitly addressed when evaluating whether man-datory COVID-19 vaccination is an ethically justifiable policy option as recommended by the WHO policy brief.
Keywords:
Subject: Public Health and Healthcare - Public Health and Health Services
1. Introduction
Coronavirus (COVID-19) pandemic sicknesses account for millions of illnesses ranging from mild to deadly, disrupting lives and healthcare systems across the globe [1]. While different safety measures have been adopted in order to curtail the spread (including wearing a face mask, maintaining a social distance of at least one meter apart, washing hands with soap and water, or use of alcohol-based hand sanitizer), the development of vaccines has been indicated to minimize the severity of the disease on an individual basis, hence reduction in the number of hospitalization as well as the number of deaths [2]. The US Department of Health and Human Services [3] emphasizes that COVID-19 vaccination became a critical tool to end the pandemic and prevent new variants of COVID-19. COVID-19 vaccines are Messenger RNA vaccines (also called mRNA virus vaccines). These mRNA vaccines make proteins in order to trigger an immune response. According to the US Department of Health and Human Services [3], mRNA vaccines have shorter manufacturing times with no risk of causing disease in the person getting vaccinated.
Thus, the WHO [4] found vaccines to be the safest way to achieve herd immunity (which is defined as a situation when most of the population is immune to infection and bringing an end to this pandemic through vaccines [5]. Vaccines are now widely available for everyone six months and older, and the CDC recommends one booster for everyone five years and older and an additional booster for specific immunocompromised individuals and everyone 50 years and older [6]. Thus, as of Feb 11, 2022, about 54.4% of the global population was fully vaccinated, 62.35% had taken one dose of the covid-19 vaccine [7], and 15.1% had taken the booster shot [8].
- Problem statement
Despite the availability of vaccines that are exceptionally effective in reducing the risks of death and severe disease, misperceptions of COVID-19 vaccine safety, efficacy, risks, and mistrust in institutions responsible for vaccination campaigns have been reported as factors contributing to vaccine hesitancy, making vaccination rate not satisfactory, making some countries around the globe make COVID-19 vaccination 'mandatory' to increase vaccination rates in the name of discharging what governments perceived to be duties of care to at-risk populations and achieving public health goals with a limited number of exceptions, such as medical contraindications that are recognized by legitimate authorities. Vaccine mandates are a way to compel people to get vaccinations by either fining people who do not comply or excluding them from certain activities and locations, like hospitality venues or workplaces [9].
- Research Rationale
What information is available in the literature about mandatory vaccination implementation globally needs to be clarified. For these reasons, a scoping review was conducted to systematically map the research in this area and identify any existing gaps in knowledge.
- Objectives
- Describe how countries globally implemented mandatory vaccination.
- Explore the reaction of citizens in countries implementing mandatory vaccination globally.
2. Materials and Methods
The scoping review followed the five steps described by Arksey and O'Malley [10] supported by PRISMA Extension for Scoping Reviews (PRISMA-ScR) [11], which included the following:
- Identifying the research question
- Identifying relevant studies
- Study selection
- Charting the data/data extraction
- Collating, summarizing, and reporting on the data.
Quality assessment of each of the included primary studies was done as described by Levac et al. [12].
- Identifying the research questions
This review aimed to identify current literature on mandatory vaccination against COVID-19 as adopted by several countries globally. The research questions are as follows.
- Which countries have adopted mandatory vaccination against covid-19?
- How are they implementing it?
- What is the reaction of citizens to mandatory vaccination?
- Search strategy
A Google Scholar database was used to search for literature matching the research questions, and keywords such as mandatory, vaccination, COVID-19, attitudes, reactions, and citizen were employed in the search for studies from Google Scholar between December 2019 to January 2022. This scoping review considered all relevant studies, including opinion papers, editorials, and published news analyses, irrespective of research design.
- Selection of studies
On Jan 31, 2022, Damian searched the google scholar database and obtained 140 studies. Two duplicate studies were excluded after the primary reviewer thoroughly screened by title. The two reviewers (Damian, J.U and Takalani, T.G) screened the 138 studies by abstracts. About 85 studies were excluded for non-accessibility [13]. About 53 studies' full text were screened for relevance, and about 29 were excluded for not addressing the study's objectives. The reviewers reached an agreement on the 24 studies that were eligible for the review (See PRISMA flow diagram below):
Figure 1.
PRISMA flow diagram for data selection process [14].
Figure 1.
PRISMA flow diagram for data selection process [14].
Data extraction
The data extraction form was designed in agreement with the reviewers on which information is relevant for the study.
- Citation information.
- Aim of study and timing for study -before or after policy adoption on vaccine mandate.
- Participants on whom the vaccine mandate was applicable.
3. Results
A total of 24 publications, irrespective of their methodology, were included in this review after screening. The characteristics of the studies included 10 Peer-reviewed studies, 4 Opinion papers, 4 Commentary, 3 News, 1 News analysis, Editorial, 1 Research letter, and 1 Article. About 3 of the ten peer-reviewed studies were from Australia, two from Saudi Arabia, the rest from Nigeria, Mongolia, France, Greece, and Germany, and none from the United Kingdom and the United States of America, respectively. Participants included in the studies were from different sectors of the economy aged 18 years and above. The included publications represented data from 9 countries, with eight publications from the United Kingdom; no country from South America was represented (see pie chart below for more information).
Figure 2.
Pie chart showing the distribution of countries that adopted the mandatory covid-19 vaccination as indicated by studies.
Figure 2.
Pie chart showing the distribution of countries that adopted the mandatory covid-19 vaccination as indicated by studies.
With regards to the implementation of the mandatory Covid-19 vaccination, 11 studies indicated that these countries, France, Mongolia, the United Kingdom, Australia, United States of America, applied the policy to their healthcare workers, with France extending it to eligible citizens from the general population using vaccine passport. Additional to implementing the policy on healthcare workers, the United States of America adopted the COVID-19 mandatory vaccine in the business sector as well as their military. A summary is provided in Table 3.
Table 5.
reaction of citizens on mandatory covid-19 vaccination after policy adoption.
| Author | Country | Citizen’s reaction to mandatory covid-19 vaccination |
| Turbat, B et al. | Mongolia | 93.7% agreement rate towards mandatory Covid-19 vaccination. |
| Wang et al. | Australia | Although respondents supported mandatory COVID-19 vaccination in South Australia, it was the least accepted vaccination strategy. |
| Gareth lacobucci | United Kingdom- England | -The British Medical Association (BMA) supports the move for every healthcare worker to be vaccinated against COVID-19, but it has some reservations about its "complicated and practical issues."
|
| Daniel Sokol | United Kingdom | The writer believes that healthcare workers in the United Kingdom (unless exempted) should adhere to the mandatory vaccination policy because it will boost vaccine uptake. |
| Owen Dyer | United States of America | Reaction from the business world to the presidential executive order on COVID-10vaccine mandate was muted. |
| Michael Mittelman | United States of America | A kidney transplant patient comments '' I hope mandatory vaccination rules become universal, with only medical exemptions permitted. It would alleviate some of my anxiety in receiving care''. |
| Lydia Hayes and Allyson M Pollock | United Kingdom | Asserts that making COVID-19 vaccination compulsory for care home workers is ‘’unnecessary’’, ‘’disproportionate’’ and ‘’misguided’’ |
| Stokel-Walker. C | United Kingdom | The article mentioned; the United States of America, Saudi Arabia, Italy, Russia, the Republic of Ireland (although not adopted by the government, some hospital trusts have already implemented it.), France (but not including care homes as of when this article was published) is a country that has mandated COVID-19 vaccination for their healthcare workers |
| Marta Paterlini | United Kingdom | Some opinions suggested that in addition to the mandatory COVID-19 vaccination, there should be a legally backed consequence for failure to comply with the rule by health workers. |
4. Discussion
The evidence retrieved from the review is few about the number of countries in the world and that almost every part of the world was affected by the coronavirus 2019 pandemic. The Covid-19 pandemic has gained the interest of many since its first identification, with several articles published about its mode of transmission, safety measures, herd immunity, vaccine safety, and hesitancy, as well as mandatory covid-19 vaccination policy [2,5,8,15,16]
- Countries that adopted the mandatory covid-19 vaccination
As presented in 9 studies reviewed, countries mapped out for adopting the mandatory covid-19 vaccination includes Mongolia, Australia, the United States of America, and the United Kingdom, with France, Russia, Saudi Arabia, Ireland, and Italy, as mentioned by [17]. Although the study by Gagneux-Brunon, A. et al. [18] identified France, the study was carried out before policy adoption to assess citizens’ attitudes toward mandatory COVID-19 vaccination in France before the announcement. Countries like; Germany [19], Nigeria [20], Greece [21], and Austria [22,23,24] were also mentioned, but these peer-reviewed studies were carried out before the policy on covid-19 vaccine mandate was adopted by these countries. Although all were published after covid-19 vaccine mandate policy adoption, articles that reported that the United States of America and the United Kingdom were either opinion papers, news analyses, editorials, news, or commentary, except a report on the United States of America by Largent et al. [25] which was a research letter based on a completed study carried out on 2730 adults aged 18 years and above-no peer-review study were retrieved for this scoping review.
- Mandatory COVID-19 Vaccination Policy Implementation and the Reaction of Citizens
On implementing the adopted policy on mandatory Covid-19 vaccination, for some countries identified its adoption, a difference exists in terms of the types of workers, situations, and strictness in insisting on vaccination [17]. Eleven out of twenty-four studies reported possible or ongoing implementation of the mandatory covid-19 vaccination policy specifically on healthcare workers in six countries: France, Mongolia, Australia, the United States of America, the United Kingdom, and Italy. These reports align with the report by Giannouchos et al. [26], which highlighted that different countries prioritize healthcare workers regarding the COVID-19 vaccine allocation plan. Although 41.9% of study respondents opposed the mandatory covid-19 policy in France [18], 30.5% of those who are against it are entirely in favor that the vaccine mandate policy being applied to healthcare workers instead of the general public. This decision, according to Giubilini [27,28,29], is justified by the healthcare workers’ protection right, which is to be protected from occupational infection or the protection of patients from being infected by the healthcare worker and also because the health workers are also an essential source of information for vaccination for others [17].
In order to protect the healthcare workers, different countries used several methods to implement the vaccine mandate policy [17], the Italian government took a stance on suspending healthcare workers that refused to vaccinate, and the suspension comes without pay for a year. This move was after several hospital infections were linked to unvaccinated healthcare workers. Meanwhile, at the time of this publication by Stokvel-Walker [17], the Irish government did not enforce mandatory covid-19 on healthcare workers, and some hospitals sent unvaccinated staff home on full pay to protect the patients. Kamlesh et al. [30] wrote a commentary with the opinion that support for mandatory covid-19 vaccination could be perceived as discriminatory and may lead to stigmatization and a wider gap in the trust from the healthcare workers to the government so instead, approaches should address vaccine hesitancy among healthcare workers like; "sharing information about vaccine safety and efficacy, risk perceptions and perceived need of vaccination, and use of trusted, credible sources" should be adopted which according to Baskin [31] has been proven to increase the rate of uptake of seasonal influenza vaccination among the general public.
A study (by King et al. [32] in Austria, which aimed to give guidance on the issue of human rights with regards to covid-19 by a worldwide network of jurists, opined that mandatory vaccination is compatible with human rights law, but care should be taken in designing its requirement of the policy so that it does not interfere with individual fundamental rights. The stand of the jurists may be synonymous with this article from the United Kingdom, Savulescu [33], stating that the choice of paying individuals for a vaccination with cash or in kind as a means of achieving herd immunity may be an ethically superior option when compared to the stance of "no jab no job" for its employees in public, private and also non-governmental agencies in Saudi Arabia [17,34,35].
Given the executive order by President Joe Biden of the United States of America for employees to vaccinate or undergo weekly covid-19 testing, Dryer [36] reported that several governors from the Republican-led state vowed to fight the executive order in court also on this same issue, the reaction from the business world on the presidential executive order on covid-19 vaccine mandate in the American business sector was muted. Meanwhile, Krik and Reese [3] justify the call for mandatory vaccination of the United States of America military based on ethics.
5. Conclusions
The study found that only 11 out of 195 countries were documented for adopting the mandatory covid-10 vaccination policy. Furthermore, this review also highlighted that most participants' and authors' reactions support the mandatory covid-19 vaccination, while few affirmed but on the condition that ethical issues should be considered. This section is not mandatory but may be added if there are patents resulting from the work reported in this manuscript. Policymakers should use less intrusive means or methods to encourage voluntary vaccination against COVID-19 before contemplating mandatory vaccination. In other words, mandates should be considered after people have been allowed to get vaccinated voluntarily. Once there is sufficient reason to believe this alone will not be enough to achieve meaningful societal or institutional objectives. Efforts should be made to demonstrate the health risks of not being vaccinated and the benefit and safety of vaccines for the most remarkable possible acceptance of vaccination. Several ethical considerations should be explicitly discussed and addressed through ethical analysis when evaluating whether mandatory COVID-19 vaccination is an ethically justifiable policy option. Just as is the case for other public health policies, decisions about mandatory vaccination should be supported by the best available evidence and made by legitimate decision-makers in a transparent, just, fair, and non-discriminatory manner involving the input of affected parties.
Informed Consent Statement Not applicable
Author Contributions
Conceptualization, UJ. and TG.; methodology, UJ. and TG.; software, X.X.; validation, UJ. and TG. writing—original draft preparation, UJ writing—review and editing, TG.; supervision, TG All authors have read and agreed to the published version of the manuscript.
Funding
Please add: “This research received no external funding
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of University of Venda (SHS/20/PH/23/0110 October 2021).
Data Availability Statement
Not applicable
Acknowledgments
None
Conflicts of Interest
The authors declare no conflict of interest.
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Table 3.
Studies showing the implementation of the mandatory covid-19 vaccine on the citizens.
| Reference | Implementation of policy on mandatory covid-19 vaccination (on whom) | |||||
|---|---|---|---|---|---|---|
| Reference | Vaccine passport | Eligible citizens from the population eligible for vaccination | Health care sector | Business Sector |
Military | Other exposed professionals |
| Gagneux-Brunon A. et al Turbat, B et al. Kamlesh et al. Leask et al. Klompas et al. Gareth lacobucci Daniel Sokol Jacqui Wise Lydia Hayes and Allyson M Pollock Stokel-Walker. C Marta Paterlini |
France | France, Mongolia, United Kingdom, Australia, United States of America, United Kingdom, United Kingdom, United Kingdom, United Kingdom, United Kingdom, United Kingdom, Italy, | ||||
|
Australia, Germany, Greece, Australia, United States of America, Austria, Australia, Nigeria, Saudi Arabia, Saudi Arabia, Russia, the Republic of Ireland, | |||||
|
United States of America, Russia | |||||
|
France | |||||
|
United States of America | |||||
Table 4.
Reaction of citizens on mandatory covid-19 vaccination before policy adoption.
| Authors | Country | Citizen’s reaction to mandatory covid-19 vaccination |
| Gagneux-Brunon A. et al | France | 43% of the respondents favored the policy, 41.9% opposed it, 30.05% of this group that mandatory covid-19 vaccination be applied to healthcare workers, while 15.15% were undecided. |
| Smith et al. | Australia | Respondents in this study reacted positively, with 73% affirmative response to adopting mandatory covid-19 vaccine but only for travel, work, and school. There is a 12% decrease in positive responses. When compared with previous studies on the same issue, |
| Graeber et al. | Germany | Study respondents showed 60% approval for the mandatory covid-19 vaccination, and 27% did not approve of the policy. |
| Giannouchos et al. | Greece | 74% of the respondents supported mandatory vaccination. |
| Savulescu J | United Kingdom | Highlighted mandatory covid-19 vaccination as the ethical means of achieving herd immunity but should be accompanied by monetary compensation to the individual. |
| Kamlesh et al. | United Kingdom | Mandatory covid-19 vaccination on health workers.
|
| Leask et al. | Australia | Regarding health workers, there is justification for the vaccine mandate, especially when there is a high risk of them being infected or infecting others at greater risk of severe effects of COVID-19. In the case of the eligible general population.
|
| Klompas et al. | United States of America | The authors presented in the study support mandatory COVID-19 vaccination for healthcare workers. |
| Largent et al. | United States of America | The authors highlighted that the respondents accepted the covid-19 vaccine mandate and will likely go for vaccination voluntarily. |
| King et al. | Austria | Authors believe that mandatory vaccination is compatible with human rights law, but care should be taken in designing its requirement so that it does not interfere with individual fundamental rights. |
| Amakiri et al. | Nigeria | 52% of the respondents rejected the idea of mandatory COVID-19 vaccination. |
| Jacqui Wise | United Kingdom | The writer perceived that mandating covid-19 vaccination for health workers may be counterproductive. |
| Krik and Reese | United States of America | Writers think the call for mandatory vaccination of the United States of America military is justified. |
| Alfageeh et al. | Saudi Arabia | 69.5% of respondents support that the COVID-19 vaccine should be made compulsory for the people of Saudi Arabia, while 30.5 % do not support the move. |
| Al-Hanawi et al. | Saudi Arabia | 97.81% of respondents agreed with mandatory covid-19 vaccination, while 2.19 did not. |
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