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Original Investigation
June 29, 2020

Association Between Human Papillomavirus Vaccination School-Entry Requirements and Vaccination Initiation

Author Affiliations
  • 1Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
  • 2Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
  • 3Division of Nutritional Sciences, Cornell University, Ithaca, New York
  • 4Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles
  • 5Fielding School of Public Health, Department of Epidemiology, University of California, Los Angeles
JAMA Pediatr. Published online June 29, 2020. doi:10.1001/jamapediatrics.2020.1852
Key Points

Question  Are human papillomavirus vaccination requirements for school entry associated with vaccination initiation in select regions of the US?

Findings  In this cross-sectional study, 3 US jurisdictions with human papillomavirus immunization school-entry requirements in 2017 had higher levels of vaccination initiation than jurisdictions without such policies within the same region. Compared with nonpolicy jurisdictions in the same region, all policy jurisdictions except Virginia experienced greater differential changes in prepolicy and postpolicy vaccination initiation among girls and boys.

Meaning  The findings of this study suggest that human papillomavirus vaccination school-entry requirements are associated with increased vaccination initiation.

Abstract

Importance  Human papillomavirus (HPV) vaccination coverage is suboptimal in the US. The association between HPV vaccination requirements for school entry and HPV vaccination coverage remains to be studied.

Objective  To examine the association between HPV vaccination school-entry requirements and vaccination initiation in jurisdictions with such vaccination policies (ie, Virginia, the District of Columbia, and Rhode Island) compared with other regions of the US, as determined by the National Center for Chronic Disease Prevention and Health Promotion.

Design, Setting, and Participants  In a population-based, cross-sectional study, 2017 data from the National Immunization Survey–Teen database were used to determine HPV vaccination initiation. Data from 2008 to 2017 were then examined to assess the association between HPV vaccination school-entry policies and vaccination initiation. Data were obtained for adolescents aged 13 to 17 years in the US with health care professional–reported HPV vaccination histories (cross-sectional study, n = 4784; pre-post policy comparisons, n = 42 431). This study was conducted from May 1, 2019, to March 31, 2020.

Exposures  State-level HPV vaccination school-entry requirements from 2008 to 2017.

Main Outcomes and Measures  Health care professional–confirmed HPV vaccination initiation.

Results  The 2017 cross-sectional study included 4784 adolescents aged 13 to 17 years (2228 [46.6%] girls; 2556 [53.4%] boys; mean [SD] age, 15.0 [1.4] years; interquartile range, 14-16 years). Compared with nonpolicy jurisdictions within the same region, Rhode Island and the District of Columbia, which have HPV immunization school-entry requirements, had higher levels of HPV vaccination initiation (Rhode Island: adjusted odds ratio [aOR], 4.34; 95% CI, 2.16-10.00; District of Columbia: aOR, 2.35; 95% CI, 1.39-4.19). However, compared with regional nonpolicy states, Virginia’s HPV vaccination initiation did not differ significantly (aOR, 1.01; 95% CI, 0.72-1.42). The 2008-2017 pre-post policy comparisons involved 42 431 adolescents aged 13-17 years (22 362 [52.7%] girls; 20 069 [47.3%] boys; mean [SD] age, 15.0 [1.4] years; interquartile range, 14-16 years). Postpolicy levels of HPV vaccination initiation in girls was significantly higher in Rhode Island (aOR, 3.12; 95% CI, 1.92-5.07) than prepolicy values. Similar changes were noted for postpolicy HPV vaccination initiation in boys in the District of Columbia (aOR, 6.36; 95% CI, 4.27-9.46) and Rhode Island (aOR, 5.84; 95% CI, 3.92-8.69) compared with prepolicy measures. With respect to regional nonpolicy states during the same period, both girls and boys in Rhode Island and boys in the District of Columbia experienced larger increases in HPV vaccination initiation. For example, in Rhode Island, boys aged 16 to 17 years had 7.32 (95% CI, 3.56-15.06) times the change in pre-post policy HPV vaccination initiation, while girls aged 16 to 17 years had 1.28 (95% CI, 0.60-2.73) times the change. In the District of Columbia, boys had 6.36 (95% CI, 4.27-9.46) times the change in pre-post policy HPV vaccination initiation.

Conclusions and Relevance  The findings of this study suggest that HPV vaccination school-entry requirements are associated with increases in vaccination initiation. Expanding such policies may increase HPV vaccination in the US.

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