State Laws Permitting Adolescent Consent to Human Papillomavirus Vaccination and Rates of Immunization

Despite the safety and efficacy of human papillomavirus (HPV) vaccine, immunization rates remain lower than other adolescent vaccines, with only 54% of adolescents in the US up to date with the multidose series.¹ Legislation that permits adolescents to consent to HPV vaccination without parental involvement is a policy option for improving immunization rates.² While 8 states and Washington, DC, currently have policies that permit adolescents to consent to HPV vaccination, the effect of these policies on immunization rates remains unknown, to our knowledge. In this study, we investigate the association between adolescents’ ability to consent to HPV vaccination and rates of vaccine initiation and completion.

In this cross-sectional study, we analyzed National Immunization Survey–Teen (NIS-Teen), a national data set that compiles vaccination data for adolescents in the US. For 2015 through 2018, we included adolescent data with adequate clinician-reported vaccination records while applying recommended clinician sampling weights and survey procedures, which accounted for clustering by states. Because it used deidentified, publicly available data, the study did not meet the definition of human subjects research of the Yale School of Medicine’s institutional review board, and therefore ethical review and informed consent were not required.

Adolescents were classified as either permitted or not permitted to consent to HPV vaccination according to their state of residence, age, and year of survey, based on the year of enactment of state bills and laws as described by Silverman et al.² For 1 or more survey years, the following states permitted adolescents to consent to HPV vaccination: Alabama, Alaska, California, Delaware, Idaho, New York, Oregon, and South Carolina, plus Washington, DC. Logistic regression was used to examine the association between permitting adolescents to consent to HPV vaccination and vaccine uptake. Two-sided P values less than .05 were considered significant. Multivariable models were used to adjust for potential confounders. To build the full model, individual covariate assessments, collinearity diagnostics, and a stepwise forward inclusion procedure with comparisons based on the Akaike information criteria were performed. Sensitivity analysis excluded adolescents residing in states with school mandates for HPV vaccine. Analysis was completed in SAS version 9.4 (SAS Institute)³ from July 2020 to September 2021.

The data set included 81 899 adolescents aged 13 to 17 years, with 38 942 girls (49.0%) and a mean (SD) age of 15.0 (1.4) years. Sociodemographic characteristics of the overall cohort and by permission to consent to HPV vaccination are shown in Table 1.

Initiation of the HPV vaccine series was 67.9% for adolescents permitted to consent (n = 6470), compared with 61.4% for those not permitted to consent (n = 44 846; adjusted odds ratio, 1.16 [95% CI, 1.01-1.34]). Vaccine series completion was 53.7% among adolescents permitted to consent (n = 5161) compared with 47.9% among those not permitted to consent (n = 35 473; adjusted odds ratio, 1.06 [95% CI, 0.94-1.21]) (Table 2). In the sensitivity analysis, initiation of the vaccine series remained significantly associated with the ability to consent (adjusted odds ratio, 1.16 [1.01-1.34]).

Laws that permit adolescents to consent to HPV vaccination are either in a scope of laws allowing adolescents to make independent decisions on sexual health, or less commonly, in a more general scope of preventive health inclusive of vaccines.² Our analysis showed a significant positive association between adolescents being permitted to consent to HPV vaccination by state laws in their location of residence and increased rates of initiation of the vaccine series. This suggests that policies that permit adolescents to consent to HPV vaccination could be an important strategy toward improving vaccine initiation among young adolescents, when the vaccine is likely to be most effective. Given the cross-sectional nature of these analyses, we are unable to establish causality. States with certain characteristics that are associated with immunization rates may also be more or less likely to pass laws permitting adolescents to give consent. However, it is notable that states permitting adolescent consent to HPV vaccinations are highly diverse with respect to geography, population, and demographic variables. Further work is needed to better understand the associations between policies permitting adolescent consent to vaccinations and immunization rates.

Accepted for Publication: September 15, 2021.

Published Online: November 15, 2021. doi:10.1001/jamapediatrics.2021.4591

Corresponding Author: Sangini S. Sheth, MD, MPH, Department of Obstetrics, Gynecology, and Reproductive Services, Yale School of Medicine, 330 Cedar St, FMB 339E, New Haven, CT 06510 (sangini.sheth@yale.edu).

Author Contributions: Dr Sheth had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Torres, Johnson, Oliveira, Niccolai, Sheth.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Torres, Sheth.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Johnson, Ellingson, Niccolai.

Administrative, technical, or material support: Hansen.

Supervision: Oliveira, Niccolai, Sheth.

Conflict of Interest Disclosures: Dr Sheth receives human papillomavirus vaccine as a drug-only grant from Merck for a research study and has previously served a consultant for Merck outside the submitted work; Dr Sheth also reported grants from the National Cancer Institute and the National Institute of Allergy and Infectious Diseases during the conduct of the study. Dr Niccolai reported receiving personal fees for serving as a scientific adviser to Merck during the conduct of the study. Dr Hansen reported employment with Pfizer outside the submitted work. Dr Oliveira reported grants from the National Institute of Allergy and Infectious Diseases (grant 1R01AI123204-01A1) and the National Center for Advancing Translational Sciences (grant 5KL2TR001862-03) during the conduct of the study and grants from the National Institute of Allergy and Infectious Diseases (grant 1K23AI159518-01), Pfizer (as a site coinvestigator for respiratory syncytial virus and COVID-19 vaccine clinical trials), and Gilead (site coinvestigator for remdesivir clinical trials) outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported in part from grants by the National Institutes of Health (grants R01AI123204 [Drs Niccolai, Sheth, and Oliveira], K07CA230234 [Dr Sheth], and KL2TR001862 [Dr Oliveira]).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.