Association of State Legislation of Human Papillomavirus Vaccination with Vaccine Uptake Among Adolescents in the United States

  • Nadja A. VielotEmail author
  • Anne M. Butler
  • Justin G. Trogdon
  • Ramya Ramadas
  • Jennifer S. Smith
  • Amy Eyler
Original Paper


We assessed the association of state legislation with adolescent human papillomavirus (HPV) vaccination rates in states that legislated information dissemination or administration of HPV vaccination. Using insurance claims, we calculated monthly HPV vaccination rates (November 2009–December 2017) among adolescents in states that passed HPV vaccination legislation during that period: Missouri (July 2010), Kentucky (February 2012), Indiana (March 2013), Oregon (June 2013). We used segmented regression to estimate levels and trends of HPV vaccination rates, comparing pre-legislation to post-legislation segments, adjusting for seasonal vaccination patterns and changes to the vaccination recommendation among males during the study period. Indiana’s legislation allowed pharmacists to administer HPV vaccination; legislation in Kentucky, Missouri, and Oregon included provisions HPV and cervical cancer education. No statistically significant increases in HPV vaccination levels or trends were observed in the post-legislation segments among adolescents overall; however, a significant post-legislation increase in vaccination trends was observed among boys in Missouri (β = 0.16, p = 0.03). Evidence for a positive impact of legislation on HPV vaccination rates is limited. The scarcity of policies that directly facilitate or promote HPV vaccination, and the breadth of exemptions to school vaccination requirements, may limit the effectiveness of these policies. Continuing efforts to introduce and pass legislation that directly facilitates HPV vaccination, combined with promoting existing evidence-based interventions, can provide opportunities to identify the most effective strategies to increase adolescent HPV vaccination rates.


Human papillomavirus Vaccination Adolescents Legislation Policy Time series analysis Segmented regression 



Preliminary results from this study were presented orally at the EUROGIN 2018 International Multidisciplinary HPV Congress in Lisbon, Portugal, December 2–5, 2018. Dr. Butler is supported by a grant from the National Center for Advancing Translational Sciences (NCATS), NIH, under award number KL2 TR002346.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Centers for Disease Control and Prevention. (2011). General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (Vol. 60).Google Scholar
  2. 2.
    Walker, T., Elam-Evans, L., Yankey, D., Markowitz, L., Williams, C., Mbaeyi, S., et al. (2018). National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2017. Morbidity and Mortality Weekly Report, 67(33), 909–917.CrossRefGoogle Scholar
  3. 3.
    Office of Disease Prevention and Health Promotion. (2018). Healthy people 2020: Immunization and infectious diseases. Retrieved August 8, 2018, from
  4. 4.
    Vielot, N. A., Butler, A. M., Brookhart, M. A., Becker-Dreps, S., & Smith, J. S. (2017). Patterns of use of human papillomavirus and other adolescent vaccines in the United States. Journal of Adolescent Health, 61(3), 281–287. Scholar
  5. 5.
    Immunization Action Coalition. (2017). Tdap booster requirements for secondary schools. Retrieved July 25, 2018, from
  6. 6.
    Immunization Action Coalition. (2017). Meningococcal ACWY State mandates for elementary and secondary schools. Retrieved July 25, 2018, from
  7. 7.
    Immunization Action Coalition. (2017). HPV Mandates for children in secondary schools. Retrieved July 25, 2018, from
  8. 8.
    Centers for Disease Control and Prevention. (2016). School vaccination requirements and exemptions. Retrieved September 21, 2016, from
  9. 9.
    National Conference of State Legislatures. (2016). HPV Vaccine: State Legislation and Statues. Retrieved October 3, 2016, from
  10. 10.
    Keim-Malpass, J., Mitchell, E. M., DeGuzman, P. B., Stoler, M. H., & Kennedy, C. (2017). Legislative activity related to the human papillomavirus (HPV) vaccine in the United States (2006–2015): A need for evidence-based policy. Risk Management and Healthcare Policy, 10, 29–32. Scholar
  11. 11.
    Trogdon, J. G., Shafer, P. R., Shah, P. D., & Calo, W. A. (2016). Are state laws granting pharmacists authority to vaccinate associated with HPV vaccination rates among adolescents? Vaccine, 34(38), 4514–4519. Scholar
  12. 12.
    Perkins, R. B., Lin, M., Wallington, S. F., & Hanchate, A. D. (2016). Impact of school-entry and education mandates by states on HPV vaccination coverage: Analysis of the 2009–2013 National Immunization Survey-Teen. Human Vaccines and Immunotherapeutics, 12(6), 1615–1622. Scholar
  13. 13.
    Thompson, E. L., Livingston, M. D., Daley, E. M., & Zimet, G. D. (2018). Human papillomavirus vaccine initiation for adolescents following Rhode Island’s school-entry requirement, 2010–2016. American Journal of Public Health, 108(10), 1421–1423. Scholar
  14. 14.
    LexisNexis. (2016). LexisNexis: Legal and professional. Retrieved November 2, 2016, from
  15. 15.
    National Council of State Legislatures. (2018). HPV Vaccine: State legislation and statutes. Retrieved August 8, 2018, from
  16. 16.
    Bernal, J. L., Cummins, S., & Gasparrini, A. (2016). Interrupted time series regression for the evaluation of public health interventions: A tutorial. International Journal of Epidemiology, 46(1), 348–355. Scholar
  17. 17.
    Dunne, E. F., Markowitz, L. E., Chesson, H., Curtis, C. R., Saraiya, M., Gee, J., et al. (2011). Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. Morbidity and Mortality Weekly Report, 60(50), 1705–1708.Google Scholar
  18. 18.
    Wagner, A., Soumerai, S., Zhang, F., & Ross-degnan, D. (2002). Segmented regression analysis of interrupted time series studies in medication use research. Journal of Clinical Pharmacy and Therapeutics, 27(4), 299–309. Scholar
  19. 19.
    Centers for Disease Control and Prevention (CDC). (2018). Results for adolescent HPV vaccination coverage. TeenVaxViewInteractive! Retrieved October 17, 2018, from
  20. 20.
    Carpenter, C. S., & Lawler, E. C. (2017). Direct and spillover effects of middle school vaccination requirements. National bureau of economic research working paper series (Vol. No. 23107).
  21. 21.
    Deshmukh, U., Oliveira, C. R., Griggs, S., Coleman, E., Avni-Singer, L., Pathy, S., et al. (2018). Impact of a clinical interventions bundle on uptake of HPV vaccine at an OB/GYN clinic. Vaccine, 36(25), 3599–3605. Scholar
  22. 22.
    Vielot, N. A., Islam, J. Y., Sanusi, B., Myers, J., Smith, S. B., & Meadows, B., et al. (2018). Overcoming barriers to adolescent vaccination: perspectives from champion vaccine providers in North Carolina, USA. In 32nd International Papillomavirus Conference. Sydney, Australia.Google Scholar
  23. 23.
    Gilkey, M. B., Calo, W. A., Moss, J. L., Shah, P. D., Marciniak, M. W., & Brewer, N. T. (2016). Provider communication and HPV vaccination: The impact of recommendation quality. Vaccine, 34(9), 1187–1192. Scholar
  24. 24.
    Mohammed, K. A., Geneus, C. J., Osazuwa-Peters, N., Adjei Boakye, E., Tobo, B. B., & Burroughs, T. E. (2016). Disparities in provider recommendation of human papillomavirus aaccination for U.S. adolescents. Journal of Adolescent Health, 59, 592–598. Scholar
  25. 25.
    Cunningham, P. (2011). State variation in primary care physician supply: Implications for health reform medicaid expansions. Princeton, NJ. Retrieved from
  26. 26.
    Crosby, R. A., Casey, B. R., Vanderpool, R., Collins, T., & Moore, G. R. (2011). Uptake of free HPV vaccination among young women: A comparison of rural versus urban rates. Journal of Rural Health, 27(4), 380–384. Scholar
  27. 27.
    Luque, J. S., Raychowdhury, S., & Weaver, M. (2012). Health care provider challenges for reaching Hispanic immigrants with HPV vaccination in rural Georgia. Rural and Remote Health, 12(2), 1–9. Scholar
  28. 28.
    Thomas, T., Strickland, O., DiClemente, R., Higgins, M., & Haber, M. (2012). Rural African American parents’ knowledge and decisions about human papillomavirus vaccination. Journal of Nursing Scholarship, 44(4), 358–367. Scholar
  29. 29. (2018). Increasing HPV Immunization Rates: The Rural Adolescent Vaccine Enterprise (RAVE). Retrieved August 17, 2018, from
  30. 30.
    The University of Iowa College of Public Health. (2017). UI to study HPV vaccine disparities in rural areas. Retrieved August 17, 2018, from
  31. 31.
    Community Preventive Services Task Force. (2016). Increasing appropriate vaccination: Vaccination requirements for child care, school, and college attendance: Task Force finding and rationale statement. Retrieved from
  32. 32.
    Suma, S. (2008). Legislative Responses to the HPV Vaccine: School Enrollment “Requirements” that are Optional to Parents. Chicago, IL. Retrieved from
  33. 33.
    Roberts, M. C., Murphy, T., Moss, J. L., Wheldon, C. W., & Psek, W. (2018). A qualitative comparative analysis of combined state health policies related to human papillomavirus vaccine uptake in the United States. American Journal of Public Health, 108(4), 493–499. Scholar
  34. 34.
    Daley, E., Thompson, E., & Zimet, G. (2019). Human papillomavirus vaccination and school entry requirements: Politically challenging, but not impossible. JAMA Pediatrics, 173(1), 6–7.CrossRefGoogle Scholar
  35. 35.
    Zhang, F., Wagner, A. K., & Ross-degnan, D. (2011). Simulation-based power calculation for designing interrupted time series analyses of health policy interventions. Journal of Clinical Epidemiology, 64(11), 1252–1261. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Family MedicineUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Division of Infectious DiseasesWashington University at St. LouisSt. LouisUSA
  3. 3.Division of Public Health SciencesWashington University at St. LouisSt. LouisUSA
  4. 4.Department of Health Policy and ManagementGillings School of Global Public Health, University of North Carolina at Chapel HillChapel HillUSA
  5. 5.Lineberger Comprehensive Cancer CenterUniversity of North Carolina at Chapel HillChapel HillUSA
  6. 6.Brown SchoolWashington University in St. LouisSt. LouisUSA
  7. 7.Department of EpidemiologyGillings School of Global Public Health, University of North Carolina at Chapel HillChapel HillUSA

Personalised recommendations