Linking Immunization Status and Eligibility for Welfare and Benefits Payments: The Australian "No Jab, No Pay" Legislation.

The recent outbreaks of vaccine-preventable diseases have refocused attention on the threat posed by unvaccinated and undervaccinated individuals.1 Governmentsaroundtheworldhaverespondedbystrengthening laws and policies directed at increasing vaccination rates. The standard menu of options includes education and information initiatives, incentives, and mandates; thesemay be directed at the general public, health care organizations, or practitioners. Thetermmandate is somewhatmisleading,because there are exceptions1—always on medical grounds, frequently on religious grounds, and sometimes on philosophicalgrounds.Moreover, thethrustofmandates isnot to forcibly require vaccination but to predicate eligibility foraserviceorbenefitonadherencetotherecommended immunizationscheduleofvaccination.IntheUnitedStates, every state requiresproofof immunization forentry into public schools, andsomestatesalsohavesimilar requirementsforentry intodaycarefacilitiesandprivateschools. Theserequirementscanseemcoercivetofamilieswhodo not have other feasible schooling or child care options. However,thelogicandacceptabilityoftheserequirements arerootedinthefactthattherisksposedbyclustersofnonimmunizedchildrenareheightenedintheseverysettings. InAustralia, half of its6 states and2 territorieshave vaccine requirements for school entry, and the 3 most populous states (New South Wales, Victoria, and Queensland) recently extended such requirements for entry to kindergartens and child care facilities. These rules overlay a more controversial policy: for nearly 20 years, theAustraliangovernmenthas linked families’ eligibility for government welfare and benefits to children’s vaccination status. In this Viewpoint, we describea recentexpansionof theAustralianprogramand consider the relevance, legality, andethicsof suchanapproach in the United States.