State legislation linked to increase in HPV vaccination in teenage girls

1. A greater proportion of teenage girls initiated the human papillomavirus (HPV) vaccine series in states where the tetanus, diphtheria, and pertussis (Tdap) booster and/or the meningococcal vaccine were required for school entry.

2. State laws requiring HPV vaccination but allowing for exemptions for any reason have not been effective at increasing HPV vaccination coverage.

Study Rundown: The majority of cervical cancers, anal carcinomas, and oropharyngeal cancers are caused by high-risk HPV strains. Vaccines capable of preventing HPV-related cancers have been developed; however, their utility has been limited due to poor uptake. With the aim of determining policy recommendations to increase vaccination rates, authors compared HPV vaccination coverage in adolescent females aged 13 to 17 years across states with varying school entry vaccination requirements. This analysis took advantage of published school entry requirement data from the Immunization Action Coalition (2007-2012) and vaccination rates from the National Immunization Survey-Teen (NIS-Teen, 2008-2012). Using these resources, they also analyzed Tdap booster and meningococcal vaccination rates and assessed the possibility of a ‘spillover’ effect into HPV vaccination. Results were consistent with such an effect—Tdap and meningococcal vaccination requirements were associated with increased coverage against their specific targets in addition to HPV. In contrast, HPV-specific legislation was largely ineffective. A limitation of this study was its failure to account for confounding variables such as ethnicity, religion, parental education, and type of schooling (homeschooled teens and those attending private schools may not be subject to the same requirements). Nevertheless, considering the controversy surrounding direct HPV legislation, targeting the spillover effect from Tdap and meningococcal vaccination may be an effective strategy to increase HPV vaccination coverage. To this end, advocacy for meningococcal vaccination legislation and discussions with teens and parents about concomitant HPV vaccination initiation could have great clinical benefit.

Click to read the study, published today in Pediatrics

Relevant Reading: Overcoming barriers to low HPV vaccine uptake in the United States: Recommendations from the National Vaccine Advisory Committee

Study Author, Jennifer Moss, PhD talks to 2 Minute Medicine: Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland.    

“When clinicians vaccinate their adolescent and young adult patients against human papillomavirus (HPV), they provide lifelong protection against several types of cancer. Most states require adolescents to receive other vaccines for school entry, but only a few states require HPV vaccination. It is safe and efficient for adolescents to receive the HPV vaccine during the same clinical encounter as the other vaccines required for school, so clinicians should encourage their patients to receive the vaccines on the same day.”

In-Depth [survey]: NIS-Teen vaccination data from 2008 to 2012 (surveying 99 921 adolescents in total) were analyzed in the context of school entry vaccination requirements published by the Immunization Action Coalition. Allowing time for new policies to take effect, 1-year lagged models were used to assess Tdap booster, meningococcal, and HPV vaccination coverage. Timeliness of vaccination (i.e., proportion of vaccinations by age 13) and a possible summer peak to meet school entry requirements were also studied. HPV coverage was based on vaccination initiation in teenage girls only, without consideration of series completion. While the number of states with Tdap and meningococcal vaccine requirements steadily increased from 2007 to 2012 (Tdap: 7 to 42 states, meningococcal vaccine: 0 to 14 states), Virginia and Washington D.C. were the only 2 with mandatory HPV vaccination from 2009 to 2012. Additionally, in contrast to the Tdap booster and meningococcal vaccine, for which state-required vaccination was associated with a >20 percentage point increase in vaccination coverage (95% CIs: 17 to 27 and 19 to 29 percentage points higher, respectively), HPV-specific state policies had very little impact on HPV vaccination coverage (95% CI: -6 to 7 percentage points difference). State-mandated Tdap and meningococcal vaccination was also associated with greater timeliness of HPV vaccination (Tdap 95% CI: 8 to 16 percentage point increase; meningococcal vaccine 95%CI: 5 to 14 percentage point increase). A greater proportion of HPV vaccines were administered during the summer months in states requiring Tdap boosters, the meningococcal vaccine, or the HPV vaccine compared to those without legislation.

Image: PD

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