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These statutes and regulations were analyzed and coded based on their legal attributes into ten broad coding questions and several sub-questions Table 1.

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Additionally, this article — because it specifically highlights references to HPV in statutes and regulations at the state level — identifies how legislatures and agencies prioritize HPV vaccination-related issues regardless of federal policies. For the purpose of this article, we will refer to both statutes and regulations as laws given that they are both legally binding and states use both mechanisms to establish vaccination requirements.

State statutes and regulations related to human papillomavirus vaccination All authors Aila Hoss , Beth E. Coding questions and sub-questions. Of the laws pulled from the search, 93 An additional three provisions were included in the results that clarified or expanded on provisions that were already collected. There are 52 statutes and 44 regulations in total Table 2. State laws focus on a number of issues around HPV vaccination including vaccine finance, school-entry requirement, vaccine recommendation, public awareness, program development, vaccine access, vaccine education, plan development, and vaccine reporting.

Reference to HPV vaccination in relevant statutes and regulations by U. States and the District of Columbia, States with laws related to school entry, parental education, U. States and District of Columbia — While only three jurisdictions require HPV vaccination as a condition for school attendance under state law, other states have established additional strategies to promote HPV vaccination in school children. Additionally, 12 states require or recommend the development or distribution of information to parents related to HPV vaccination for parents.

Two states Iowa and Texas require HPV vaccination information to be incorporated into education curricula. States also have laws that promote childhood vaccination in non-educational settings. This includes the requirement in Maine that youth camps and similar programs assess HPV vaccination status of their campers. Arkansas requires foster parents to assist in ensuring children are vaccinated for recommended vaccinations, including HPV.

Laws that seek to improve HPV vaccine access include those that provide vaccination authority to pharmacists and allow minors the ability to give consent for the vaccination Table 4. The express listing of HPV indicates that state legislators and agencies specifically considered HPV in their policymaking process. States with laws that promote vaccine access, U. Illinois allows minors 12 years or older to consent to HPV vaccination and Utah allows minors to consent if they are an abandoned minor as represented by the patient.

Some jurisdictions require individual and group health insurance plans to cover HPV vaccination while numerous states require HPV vaccine coverage via Medicaid and other health programs. Finally, public health strategies are also incorporated into statutes and regulations. Further, Colorado, Illinois, and Indiana require the establishment of department of health programs or strategic plans that include activities related to HPV vaccination. No single coding question included results from more than one-third of the jurisdictions, and many states had laws related only to one aspect of HPV access such as educational materials or vaccine financing.

Eight of the ten coding questions included results from six or fewer states. The coding questions that had the most state activity were related to developing and distributing HPV vaccination materials for parents and those related to mechanisms to fund and reimburse for the vaccination.


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Despite finding that 34 states and the District of Columbia reference HPV vaccination in statutes or regulation, there were remarkably few state laws on this topic, and few states with laws across multiple coding categories as outlined above. The observation that HPV vaccination education was a common policy outcome among states enacting law related to HPV vaccination may be an artifact of what Abiola et al.

A framework for public health action: the health impact pyramid. Even within the states that have a number of HPV vaccination-related laws, one cannot presume that a higher number of statutes and regulations indicates a comparatively higher commitment to improving HPV vaccination access across states. This is because individual states and individual acts or rulemaking within a state can vary substantially in terms of the length of a single provision when it is codified. For example, a state with ten provisions is not necessarily more active than a state with two, if the two provisions run for a much longer period than the ten.

Further, the number of results generated in the collection of laws for this study might be a function of the search, where search strings can be crafted more narrowly or more broadly with adjustments in the terms and connectors.

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While the number of provisions is not necessarily an indicator of commitment, the study found that there were nearly as many individual regulatory provisions in our results as individual statutory provisions. This reinforces the value of research across both legislation and rulemaking. Overwhelmingly, jurisdictions tend to use statutes and regulations to promote HPV vaccination, such as financial incentives or requirements for public education campaigns as opposed to laws that limited vaccination. However, there are still laws that function in practice to curb vaccination. State laws that explicitly exclude HPV vaccination from school-entry requirements and those in DC and Virginia that create an express parental opt-out for the vaccination are such examples.

Opt-out provisions that provide so much discretion to parents on HPV vaccination that, in practice, there is no realistic way to enforce the requirements. Association between vaccine refusal and vaccine-preventable diseases in the United States: A review of measles and pertussis. African cervical cancer prevention and control plans: A scoping review. J Cancer Policy. Another emerging issue which has been explored elsewhere is the tendency to focus on females for HPV related policy and interventions. Increasing efforts to reduce cervical cancer through state-level comprehensive cancer control planning.

Cancer Prev Res. That said, a study of the gendering of HPV vaccination law across time would be an important contribution to the literature. This study is subject to several limitations. First, other mechanisms independent of statutes and regulations can be used to promote HPV vaccination that was not collected as part of this study. This includes state agency policies such as state cancer plans, local government actions, and case law. Nor does this study include a summary of all federal laws that might impact HPV vaccination. Additionally, the study did not analyze the funding, implementation, or enforcement of these laws, which affect the impact of these laws in practice.

For example, laws that promote cancer and sexually transmitted infection prevention or those that fund public health prevention activities might impact HPV vaccination rates.


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There is, for example, some evidence that non-targeted adolescent vaccine school requirements may in fact impact HPV vaccination rates. School entry requirements and coverage of nontargeted adolescent vaccines.

Public Health Law Research Theory and Methods

This study utilized legal epidemiological research methods to collect and analyze statutes and regulations. Statutes and regulations from the 50 states and Washington, DC, were collected on September 3, using WestlawNext, an online legal database. From this search, statutes and regulations were identified. Following an initial review of these laws, additional statutes and regulations were added to the dataset when referenced in the provisions already collected and were relevant to HPV vaccination, or when additional provisions from the same sections or chapters of the code clarified the requirements of the original statutes and regulations.

These were collected in October and November All statutes and regulations generated from the search were preserved in pdf format, and the research process was recorded in a research procedure document. Inclusion criteria were developed following a research team conference and held that only laws expressly referencing HPV vaccination were considered relevant in this study Table 5. Thus, for example, provisions that referenced HPV in the context of screening and testing but did not mention vaccination were excluded.

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These included a provision related to the exemption of HPV vaccination in an immunization registry and the certification of the HPV vaccination as safe by a department of health. These exclusion criteria were documented in the research procedure. Inclusion and exclusion criteria flow chart. Statutes and regulations relevant to the study were analyzed and coded based on their legal attributes into ten broad coding questions and several sub-questions Table 1. These coding questions were revised as nuances across states were identified.

The analysis sought to describe the legal attributes, variabilities, and nuances in the laws across jurisdictions. Within the last year Gregory Zimet received an honorarium from Sanofi Pasteur for work on the Adolescent Immunization Initiative and received travel support from Merck to attend a conference on HPV vaccination. Table 2. Table 3. Table 4.

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Skip to Main Content. Search in: This Journal Anywhere. Advanced search. Submit an article Journal homepage. Pages Received 25 Dec Research Paper. State statutes and regulations related to human papillomavirus vaccination.

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View correction statement:. Introduction The vaccine to prevent human papillomavirus HPV related cancers has been approved for use in the United States since State statutes and regulations related to human papillomavirus vaccination All authors. Aila Hoss , Beth E. Published online: 02 July Table 1.

CSV Display Table. Results Of the laws pulled from the search, 93 Discussion Despite finding that 34 states and the District of Columbia reference HPV vaccination in statutes or regulation, there were remarkably few state laws on this topic, and few states with laws across multiple coding categories as outlined above. Methods This study utilized legal epidemiological research methods to collect and analyze statutes and regulations. Table 5. Display Table. We use cookies to help provide and enhance our service and tailor content. By continuing, you agree to the use of cookies.

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This page was processed by aws-apollo5 in 0. Skip to main content. Copy URL. Beasley School of Law. Abstract This book, published in by Jossey-Bass, describes scientific theory and methods for investigating the development, implementation and effects of public health law. Scott C.