Extension of French Vaccination Mandates: From the Recommendation of the Steering Committee of the Citizen Consultation on Vaccination to the Law

"...the mandates by themselves will not solve the issue of the growing vaccine hesitancy. This will require a comprehensive social marketing and communication strategy."

On December 4 2017, French parliamentarians passed a law extending the vaccination mandates for children up to 2 years of age from 3 vaccinations (against diphtheria, tetanus, and poliomyelitis - DTP) to 11 (e.g., pertussis). This vote follows a recommendation made by the Steering Committee of the Citizen Consultation on Vaccination. This article describes the historical background of this evolution and its main epidemiological, sociological, and policy drivers (e.g., growing vaccine hesitancy in the French population). It also discusses some of the challenges and conditions of success.

In January 2016, the Minister of Health organised the Citizen Consultation on vaccination. An 18-member steering committee was set up in March 2016 with the mission to report to the Minister before the end of the year. It was composed of equal numbers of civil society representatives, social scientists, and immunisation experts. They based their conclusions on 44 hearings, an internet platform that collected more than 10,000 contributions of the public, and the reports of two juries, one made up of health professionals and another one consisting of members of the general population.

The Committee made a range of recommendations to restore the population's confidence in vaccination, to facilitate access to vaccines and vaccination services, and to increase vaccine coverage. Concerning the legal status of vaccinations, the Committee recommended a temporary extension of the mandates to all vaccines to be administered to all children during their first 2 years of life. There will be no penal sanctions or fines for those who will not comply with the mandate, but no exemption other than on medical grounds will be accepted. This decision seemed to contradict a 2002 French law that recognises the principle of a "free and informed consent to any medical act and treatment" and the growing societal demand for more empowerment in the realm of health care.

The decision was based on epidemiological and sociological data and evidence provided by Santé Publique France to the Citizen Consultation. For example, in the 2016 Health Barometer survey, 13% answered that, if DTP vaccination became only recommended, they would either not (4%) or probably not (9%) vaccinate their child. The Steering Committee considered such data as an alert pledging in disfavour of the lifting of the mandates for DTP. The Committee was, however, sensitive to the risk that a mandatory measure for all infant vaccines could fuel vaccine hesitancy.

Yet, the authors opine that "the extension of the mandates should contribute to restoring confidence rather than undermining it. It may well be perceived by a large majority of the French population as a strong and positive signal of the government's commitment in favour of vaccination. It should reassure the population and the health professionals that the Ministry of Health considers the current recommended vaccines as necessary, effective and safe as those already mandatory." Furthermore, they suggest, "[s]howing proof of DTP immunisation for all forms of socialisation of children (nurseries, pre-schools, schools or any leisure activities) is part of the routine registration procedure and is well accepted both by the population and the services for children."

This new policy is intended to be temporary for the period needed to restore the confidence of the general public. Santé Publique France will conduct regular surveys monitoring trends in vaccine confidence to guide a decision if and when the mandates may be considered no longer necessary to maintain high vaccination coverage.

In that light, the "strong commitment of the current Minister of Health that resulted in the change in legislation and the wide support of GPs [general practitioners], paediatricians and infectious diseases learned societies for the extension of vaccination mandates, as assessed by their public position statement..., should be the starting point of a series of actions that will help restore confidence in vaccines." An example of such an action is Santé Publique France's launch, in April 2017, of a governmental website that provides "transparent, authoritative and evidence-based" information on vaccines and vaccination.

In conclusion: "The extension of the vaccination mandates, restricted to new birth cohorts, is only one element of a much more ambitious endeavour, which is to strengthen the French vaccination programme."