title: Systematic review of the effect of immunization mandates on uptake of routine childhood immunizations.
abstract: The efficacy of immunization mandates for childcare or school entry is a long-standing controversy. The United States (US) adopted school entry immunization mandates in the 1800s, while most countries still do not have mandates. The objective of this systematic review was to analyze the evidence that immunization uptake increases with mandates.
  
  
  
  A search was conducted for studies that compared immunization uptake in a population prior to and after mandates, or in similar populations with one group having and the other not having mandates. Data were extracted and synthesized qualitatively due to the heterogeneity of study design.
  
  
  
  Eleven before-and-after studies and ten studies comparing uptake in similar populations with and without mandates were included. Studies were from the US (n = 18), France (n = 1) and Canada (n = 2). Eleven of the 21 studies looked at middle school mandates. All but two studies showed at least a trend towards increased uptake with mandates. Higher uptake was associated with a more long-standing mandate.
  
  
  
  Immunization mandates have generally led to increased short-term and long-term uptake in the group to whom the mandate applies. Many studies have centered around middle school mandates in the US and there is a paucity of studies of childcare mandates or of studies of mandates in other countries or in settings with relatively high baseline immunization uptake.
authors.affiliation: Stollery Children's Hospital and University of Alberta, Canada. Electronic address: cecilia.lee@ualberta.ca.
authors.forename: Cecilia
authors.initials: C
authors.lastname: Lee
authors.affiliation: Stollery Children's Hospital and University of Alberta, Canada. Electronic address: jr3@ualberta.ca.
authors.forename: Joan L
authors.initials: JL
authors.lastname: Robinson
mesh_terms: D002648:Child; D005260:Female; D006801:Humans; D007114:Immunization; D017589:Immunization Programs; D008297:Male; D037141:Mandatory Programs / Q000706:statistics & numerical data; D012574:Schools; D014481:United States
keywords: Immunization; Immunization uptake; Mandatory program