Impact of Australia's No Jab, No Pay policy on vaccination uptake - a before-after study in two national birth cohorts

Frank Beard; Alexandra J Hendry; Heather F Gidding; Aditi Dey; Kristine Macartney; Julie Leask; Peter McIntyre

doi:10.1016/j.lanwpc.2024.101259

Impact of Australia's No Jab, No Pay policy on vaccination uptake - a before-after study in two national birth cohorts

Lancet Reg Health West Pac. 2024 Dec 5:54:101259. doi: 10.1016/j.lanwpc.2024.101259. eCollection 2025 Jan.

Authors

Frank Beard^{1

2}, Alexandra J Hendry¹, Heather F Gidding^{1

3}, Aditi Dey^{1

4}, Kristine Macartney^{1

4}, Julie Leask^{1

2

5}, Peter McIntyre^{1

6}

Affiliations

¹ National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, NSW, 2145, Australia.
² The University of Sydney School of Public Health, NSW, 2006, Australia.
³ The University of New South Wales School of Population Health, Faculty of Medicine and Health, NSW, 2052, Australia.
⁴ The University of Sydney Faculty of Medicine and Health, NSW, 2006, Australia.
⁵ The University of Sydney Institute for Infectious Diseases, 2006, NSW, Australia.
⁶ The University of Otago Department of Women's and Children's Health, School of Medicine, Dunedin, New Zealand.

Abstract

Background: Data on impact of financial penalties for non-vaccination are sparse. Australia has required full vaccination for government family assistance payment eligibility since 1998. In 2016, the No Jab, No Pay (NJNP) policy removed registered non-medical objection as exemption option and increased eligibility assessment to yearly. We aimed to examine NJNP impact on vaccine uptake in children.

Methods: Individual-level Australian Immunisation Register data were used to assemble two-year-wide pre-/post-NJNP birth cohorts aged 1-<3 years, stratified by registered objection (yes/no) and vaccination status (zero-dose/partially vaccinated/fully vaccinated). At 5-<7 years, we measured odds ratios (ORs) and 95% confidence interval (CIs) for vaccination outcomes post-versus pre-NJNP and compared observed post-NJNP numbers with those expected if proportions pre-NJNP applied.

Findings: Pre-NJNP of 562,316 children aged 1-<3 years, 92.1% were fully vaccinated, 4.9% partially vaccinated and 3.0% zero-dose; objection was registered for 1.1% overall (23.9% of zero-dose). Post-NJNP of 615,607 aged 1-<3 years, 92.7% were fully vaccinated, 4.7% partially vaccinated, 2.6% zero-dose; objection was registered for 1.5% overall (37.7% of zero-dose). By 5-<7 years of age, full vaccination was significantly higher post-than pre-NJNP in children with registered objection (zero-dose 14.6% versus 1.2% [OR 14.1; 95% CI 10.5-18.9]; partially vaccinated 41.7% versus 8.4% [OR 7.9; 95% CI 6.4-9.7]) and without objection (zero-dose 10.1% versus 4.9% [OR 2.2; 95% CI 2.0-2.4]; partially vaccinated 39.2% versus 34.5% [OR 1.2; 95% CI 1.1-1.3]). Post-NJNP we estimated 49,510 more children (3.7% with registered objection) to be fully vaccinated than expected. Odds of remaining zero-dose were 0.38 (95% CI 0.34-0.42) with versus 0.66 (0.63-0.70) without registered objection and fewer children (9,206, 1.5%) were persistently zero-dose post-than pre-NJNP (10,696, 1.9%).

Interpretation: Full vaccination by age 5-<7 years increased post-NJNP irrespective of baseline vaccination/objection status. Relative increases were much higher among children with registered objection than without, but partially vaccinated children without objection largely accounted for numerical increases, suggesting increased eligibility assessment was more important than changes in exemption criteria.

Funding: Australian Government Department of Health and Aged Care.

Keywords: Childhood immunisation; Childhood vaccination; Financial sanctions; Immunisation coverage; Immunisation mandates; No Jab No Pay; Parent attitudes and beliefs; Public health policy design; Vaccination policy; Vaccine hesitancy; Vaccine mandates.