HPV Vaccine
Policy Landscape
Public Health Strategies
JULY
2022
ABOUT THE AUTHORS
The Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) advocates
for legal, regulatory, and policy reforms to improve the health of underserved populations,
with a focus on the needs of low-income people living with chronic illnesses and disabilities.
CHLPI works with consumers, advocates, community-based organizations, health and social
expand access to high-quality health care and nutritious, affordable food; to reduce health
disparities; to develop community advocacy capacity; and to promote more equitable and
effective health care and food systems. CHLPI is a clinical teaching program of Harvard Law
School and mentors students to become skilled, innovative, and thoughtful practitioners as
well as leaders in health, public health, and food law and policy. For more information, visit
https://www.chlpi.org.
The authors of this toolkit are:
Abbey Bowe, Moon S. Chen Jr., Julie Dang, Sarah Downer,Catherine Flores-Martin,
Alexandra Gori, Rebecca Hval, Erin McCrady, and Maryanne Tomazic
ACKNOWLEDGMENTS
This resource was made possible through the generous support of the Bristol Myers Squibb
Foundation, and through the input and collaboration of numerous community stakeholders.
It was developed in consultation with the University of California Davis Comprehensive Can-
cer Center (the Center). The Center is undertaking efforts to address low uptake rates of the
interested in the role higher education can play in promoting HPV vaccination. For more
information, visit https://health.ucdavis.edu/cancer/.
PURPOSE OF HPV VACCINE POLICY LANDSCAPE
Low uptake rates of the HPV vaccine have remained a challenge in several states. This re-
source provides a landscape overview of potential pathways to increasing HPV vaccination
rates. Our hope is that advocates are able to use this information to inform their state-based
efforts to increase vaccination rates, particularly among children and adolescents, as well as
young adults enrolled in colleges and universities. For further questions or inquiries, please
contact chlpi@law.harvard.edu.
Report design by Cambridge Creative Group.
The Center for Health Law and Policy Innovation provides information and technical as-
sistance on issues related to health reform, public health, and other areas of law. It does
not provide legal representation or advice. This document should not be considered legal
advice. For specic legal questions, consult an attorney.
3
pandemic, and while they have since re-
bounded to pre-pandemic levels, there is
still catching up to be done. Increasing HPV
vaccine uptake will require targeted policy
solutions to navigate the landscape that
COVID-19 has forever changed.
It is with this context that we present HPV
Vaccine Policy Landscape: Public Health
Strategies. This resource provides an in-depth
look at HPV vaccination pathways across
the United States and across the globe,
with a particular focus on state-level policies
that have yielded high rates of adolescent
vaccine uptake. We look at the challenges
and barriers to expanded uptake, and iden-
tify available pathways for expanded uptake,
with emphasis on school-based vaccination
campaigns, state policy approaches, and the
role of health care providers.
Our current moment shines a light on many
facets of public health policy and vaccine
uptake. It is our hope that this report will
highlight the roles that state policy-makers,
educational institutions, and health care
providers can play in improving public health
outcomes, and serve as a tool in navigating
this landscape effectively.
Foreword
Over the past two years, we have borne
witness to the enormous costs of a public
health crisis brought on by a highly trans-
missible illness, COVID-19. We have been
forced to contend with the ways in which
these enormous costs fall disproportion-
ately on Black, Indigenous, Asian American,
and Latino communities, unhoused people,
and people with disabilities. Over 900,000
people in the United States have lost their
lives to COVID-19 to date, with data collec-
tion issues continuing to limit our full un-
derstanding of the impact of the pandemic.
Furthermore, the health care cost of survival
— in delayed care, mental health impacts,
violence, and long-term COVID symptoms
— remains to be calculated.
During this time, we have also seen public
health guidance take center stage in an
increasingly polarized political climate.
Guidance and mandates around COVID-19
vaccination have been a key component of
the country’s widely successful vaccination
campaign, but have also been met with sub-
stantial pushback from those who cannot or
will not be vaccinated.
HPV vaccination rates dropped precipitous-
ly during the early months of the COVID-19
4
Introduction 5
The HPV Vaccine 6
Health Disparities 9
International Trends 10
School-Based Health Centers 10
State Legislative Action 11
State Executive Action 16
State Administrative Action 16
Practitioner Focus 16
Other Points of Access: Pharmacists and Dentists 17
Finding Opportunities among College Students 18
COVID-19 19
Conclusion 19
Resource Library 20
Appendices 21
Appendix A — A Review of Pathways for California 21
Appendix B — California Age-Adjusted
Rate of HPV-Attributable Cancers by County
23
Appendix C — Rate of Up-to-Date HPV Vaccination by State 24
CONTENTS
5
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
Introduction
The human papillomavirus (HPV) is a virus
that can cause abnormal growths on the skin
or mucus membrane and is etiologically as-
sociated with six different types of cancer. The
virus is spread through vaginal, anal, and oral
sex with someone living with HPV. Accord-
ing to the Centers for Disease Control and
Prevention (CDC), HPV is the most common
sexually transmitted infection in the United
States, with an estimated 42.5 million people
currently living with HPV and 13 million peo-
ple newly acquiring the virus each year.
1
While some people may not develop symp-
toms from HPV and may have the virus resolve
spontaneously, the virus can still present a
great danger as it can lead to six different types
of cancers, including cancer of the cervix, va-
gina, vulva, penis, anus, and oropharynx. HPV
causes nearly all cervical cancers,
2
and “90%
of anal, 69% of vaginal, 60% of oropharyngeal,
51% of vulvar, and 40% of penile cancers.”
3
Over
36,000 cases of cancer are estimated to be
caused by HPV each year in the United States.
4
In addition to the thousands of lives lost annu-
ally, HPV-associated cancers and conditions
are estimated to cost $8 billion in the United
States each year.
5
The HPV vaccine can help protect people from
HPV and HPV-associated cancers. In the Unit-
ed States alone, the HPV vaccine is estimated
to prevent around 33,000 cancer cases annu-
ally.
6
However, many states still have low HPV
vaccination rates, leaving many residents at
risk of grave and sometimes fatal illness. Even
when cervical cancer is not fatal, it can severely
affect fertility depending on time of detection
and available treatment options.
7
This map illustrates the age-adjusted rate of
HPV-attributable cancers across California
counties. The variation in rates highlights the
importance of a coordinated HPV prevention
strategy that accounts for access barriers
in both rural and urban counties. For more
information, see Appendix B.
FIGURE 1
A Look at California
Based on data from the California Cancer Registry
California County-level Age-adjusted Rates
of HPV-attributable Cancers per 100,000
people (2012‒2016)
8
Legend
Age-adjusted rate
of HPV-attributable
cancers (per 100,000)
6.0-7.9
8.0-8.9
9.0-9.9
10.0-10.9
11.0-11.9
6
individual hasn’t yet been exposed to, so it
is important to receive the vaccine before
potential exposure through sexual activity.
Even when vaccination is not possible be-
fore a person becomes sexually active, the
national Advisory Committee on Immuni-
zation Practices (ACIP) recommends “catch-
up” vaccinations for everyone up to age 26.
14
Because the HPV vaccine protects against
multiple strains of HPV, even if an individual
has been exposed to or has contracted one
protection from other strains.
WHO SHOULD GET THE
HPV VACCINE?
The HPV vaccine is most effective if adminis-
tered before potential exposure. It is recom-
mended by the CDC for all children at ages
11 or 12, and by the American Cancer Society
for children ages 9 to 12.
15
The vaccine elicits
a higher immune response from individuals
aged 11 to 12 than in older teens, meaning
that individuals who receive the vaccine be-
fore their 15
th
birthday can receive two doses
as opposed to the three doses needed for
those 15 and older.
16
HPV is also known to cause oropharyngeal
cancer, or cancer of the throat, tongue,
and tonsils.
9
Rates of HPV-associated oro-
pharyngeal cancer are rising dramatically,
with some experts suggesting this cancer
may become more common than cervical
cancer.
10
HPV currently causes around 9,000
cases of oropharyngeal cancers each year in
the United States.
11
The HPV Vaccine
WHAT IS THE HPV VACCINE?
The HPV vaccine protects against HPV and the
cancers associated with HPV. While there are
over 100 different kinds of HPV, most health
problems associated with HPV (including
cancer) are linked to a handful of types and
thus are targeted by these vaccines.
12
The vaccine can prevent
most cases of cervical cancer
if given before a person is
exposed to the virus.
It is recommended by the
CDC for all children at ages
11 or 12, and by the American
Cancer Society for children
ages 9 to 12.
The vaccine can prevent most cases of cer-
vical cancer if given before a person is ex-
posed to the virus. The vaccine also prevents
vaginal/vulvar cancer and can prevent geni-
tal warts, anal cancer, and strains of HPV re-
lated to oral cancers. While the vaccine was
originally targeted at “females aged 9‒26
years,”
13
vaccinating all people can provide
a protective effect against these cancers
by decreasing transmission. The vaccine
only protects against strains of HPV that an
7
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
through age 26 who were not previously vac-
cinated).
25
Despite these recommendations,
HPV vaccination rates in the United States
as a whole, and in most individual states,
have been consistently lower than rates
necessary to achieve strong herd immu-
nity and do not meet the national Healthy
People 2030 target of 80% HPV vaccination
uptake.
26
In 2020, 58.6% of United States ad-
olescents aged 13
–17 years were up to date
on HPV vaccination, with uptake as low as
31.9% in Mississippi.
27
According to CDC es-
timates, only Rhode Island has achieved the
Healthy People 2030 target of 80% uptake.
28
The HPV vaccine is recommended by ACIP
for everyone through the age of 26 years if
they haven’t yet been vaccinated. Adults
over the age of 26 are more likely to have
fewer sexual partners, and thus cost effec-
tiveness of providing the vaccine to that age
group tends to decline.
17
In 2019, updated
recommendations noted that shared clini-
cal decision-making was recommended to
identify people aged 27 to 45 years who may
18
THE HISTORY OF THE
HPV VACCINE
females between ages 11 and 12 to receive
the HPV vaccine through ACIP.
19
In 2011
ACIP expanded those guidelines to recom-
mend the vaccine for males between ages
11 and 12.
20
Early controversy around possible
school-age mandates for the vaccine cen-
tered on parental sensitivity to the primary
mode of HPV transmission (sexual activity).
21
Concerns about vaccine safety were investi-
gated by the Institute of Medicine and the
CDC; both entities found the vaccine to be
safe.
23,23,
Since the vaccine has been in use,
among teen girls, infection with HPV types
that cause the most HPV-related cancers
and genital warts have dropped 86%.
Among adult women, the infection rate has
dropped 71%.
24
HPV VACCINE UPTAKE IN
THE UNITED STATES
HPV vaccination has been associated with
decreased HPV prevalence in the United
States and is currently recommended by
the ACIP for people at ages 11 or 12 (with
catch-up recommendations for all people
FIGURE 2
HPV Vaccination in CA
Based on data from the National
Immunization Survey (2020)
In 2020, California had a higher rate of HPV
vaccination coverage for adolescents aged 13–17
years (62.3%) than the United States (58.6%).
29
However, California has not met the Healthy
People 2030 target of 80%.
The following table ranks states by up-to-
date HPV vaccination rates among adoles-
cents aged 13–17 years in 2020 based on data
collected by the National Immunization Sur-
vey. Participants are considered up-to-date
when they have received the recommended
doses of the HPV vaccine, either two doses if
they received the vaccine before they were
15 or three doses if they receive the vaccine
after the age of 15.
TARGET
80%
CA
62.3%
US
58.6%
8
and global groups, such as the National
Vaccine Advisory Committee and the World
Health Organization, have recommended
public health leaders develop and use strat-
egies that bolster provider communication
and that are tailored to address parental
concerns.
33
Non-physician providers, such as
pharmacists or dental health professionals,
have unique roles to play in HPV vaccination
recommendations as well, though addition-
al research and strategy development may
-
tive messaging.
34
BARRIERS TO HPV
VACCINE UPTAKE
While the HPV vaccine has been approved
for use since 2006, the country remains far
from reaching the national Healthy People
2030 target of 80% HPV vaccination uptake.
31
barriers that have led to low HPV vaccine
uptake, including inadequate provider rec-
ommendation, low parental demand, lack
sexuality-related concerns, low perceived
risk, and concerns about safety.
32
National
FIGURE 3
State Rates of Up-to-date HPV Vaccinations
Among Adolescents Aged 13‒17
Legend
Rate of Up-to-Date
HPV Vaccination
30.0-49.9%
50.0-59.9%
60.0-69.9%
70.0-79.9%
80.0-89.9%
Based on data from the National Immunization Survey (2020)
30
With vaccination strategies developed at the state level, there is considerable varia-
tion in HPV vaccination rates across the country. This map illustrates up-to-date HPV
vaccination among adolescents aged 13‒17. For more information, see Appendix C.
D.C.
RI
9
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
awareness is on par with white parents, Af-
less likely to vaccinate their daughters.
39
In
another example, a U.S. study found that
lesbian respondents with vaccine awareness
were less likely (8.5%) to initiate vaccination
compared to bisexual respondents (33.2%)
and heterosexual counterparts (28.4%).
40
Studies focused on vaccine uptake among
LGBTQ+ youth highlight gaps in provider
recommendations and HPV education ef-
forts for sexual minority men and transgen-
der women, despite high HPV incidence and
prevalence among these groups.
41
A study of
transgender women in Chicago and Los An-
geles found that young transgender women
have particularly low HPV and HPV vaccine
knowledge.
42
Thus, effective public health
campaigns should strongly consider the lo-
cal target population and seek out multiple,
vaccination uptake.
43
CERVICAL CANCER DISPARITIES
Examination of cervical cancer incidence
and mortality rates reveal disparities among
different communities and racial groups.
Researchers have observed disparities in
incidence of cervical cancer between urban
and rural communities, with a higher rate
of cervical cancer in rural communities. This
could be a result of barriers to cervical can-
cer prevention, detection, and treatment.
44
There are also racial disparities in cervical can-
cer incidence and mortality rates. Nationally,
Latina women have the highest age-adjusted
Health Disparities
DISPARITIES IN HPV
VACCINE KNOWLEDGE,
ACCESS, & UPTAKE
Unfortunately, HPV vaccine knowledge and
uptake varies among race/ethnicity, gen-
ders and sexual orientations. Studies have
found that non-Hispanic Black and Hispanic
individuals are less likely than non-Hispanic
whites to have heard of HPV and the HPV
vaccine, despite higher burden of cervical
cancer in these communities.
35
Additional-
ly, women are more likely than men to be
aware of HPV and the HPV vaccine.
36
Similar trends can be seen in local
studies among parents. For example, a
study of parents in Los Angeles County,
California found that “parents who were
-
cantly less aware” of HPV vaccination.
37
In another study, parents of uninsured
children, parents with lower incomes,
parents whose primary language was
not English, and parents born outside
of the United States were also less likely
to have heard of HPV vaccines.
38
While many studies have shown knowledge
and access to lead to increased uptake,
For example, a study based in Los Angeles
County found that even when HPV vaccine
10
grades with the intended age range based
on national recommendations. The vaccines
are paid for by the government. Australia
has observed higher uptake rates with this
method than with other strategies, such as
making the vaccine mandatory for school
entry or vaccination through an individual’s
general practitioner.
51
School-based vac-
cination programs in Spain, Scotland, and
Switzerland achieved completion rates of
77.3%, 81.0%, and 61.4%, respectively.
52
Internationally, school-
based vaccination
programs have proven to
be particularly successful
in increasing rates of HPV
vaccine uptake.
Developing countries with school-based
programs also have high vaccination rates.
Program for Appropriate Technology in
-
tion, partnered with the governments of four
countries to provide the HPV vaccine free at
schools and clinics. This program led to high
completion rates in India (87.8%), Peru (82.6%),
Uganda (88.9%), and Vietnam (98.6%).
53
School-Based
Vaccination Programs
in the United States
School based vaccination programs decrease
barriers to access by partnering with health
care providers to provide vaccinations during
school hours on school campuses. The ACIP
includes school-based vaccination programs
under recommendations in the General
Best Practice Guidelines for Immunization.
54
incidence rate per 100,000 women (9) of cer-
vical cancer compared with Black (8), white
Indian/Alaska Native (6) women.
45
Despite having higher rates of recent Pap
testing to screen for cervical cancer (75%
of Black women compared to 69% of white
women), Black women have the highest
mortality rate associated with the disease.
46
A recent study showed that the 2000–2012
mortality rate for Black women in the Unit-
ed States was 5.4 women per 100,000, while
the mortality rate for white women was 2.4
per 100,000.
47
Systemic racism and its im-
pact on treatment access, continuity of care,
and patient-provider relationships is likely
to account for some of the disproportionate
impact of cervical cancer on Black women.
48
International Trends
Approximately 99 countries and territories
have introduced HPV vaccination programs in
the last 10 years.
49
With varying rates of success
in increasing uptake of the HPV vaccination, a
look into international trends can help inform
stakeholders looking to increase uptake of the
HPV vaccination in their jurisdictions.
SCHOOL-BASED VACCINATION
PROGRAMS
Internationally, school-based vaccination
programs have proven to be particularly
successful in increasing rates of HPV vaccine
uptake.
50
These programs provide vaccine
access to diverse populations, regardless
of individual access to healthcare. Austral-
ia, for example, has a robust school-based
vaccination program that sends local teams
of trained providers to schools and targets
11
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
Studies in Denver and Seattle suggest that
use of SBHCs may increase uptake of the
HPV vaccine. SBHCs in Denver were used to
and a study found the program effectively
increased uptake of the vaccine.
62
A study
of SBHCs in Seattle found that female SBHC
users had 37% higher odds of completing
the series at any time compared with SBHC
nonusers, and male SBHC users had 45%
higher odds of completing the series at
any time compared with SBHC nonusers.
63
These results suggest that SBHCs create
a considerable opportunity to work with
co-located schools to implement successful
school based HPV vaccination programs.
State Legislative Action
One potential pathway to increasing rates of
completion of the HPV vaccine is through
legislative action. Out of the 18 states (in-
cluding the District of Columbia) that have
higher rates of uptake of the HPV vaccine
than California,
64
ten have passed some type
of legislation related to the vaccine. Three
have administrative or legislative mandates
requiring vaccination for public school at-
tendance, seven have provisions aimed at
easing the cost of the HPV vaccine, and three
have used legislation to establish programs
that promote education on HPV, cervical
cancer, and the HPV vaccine. This section
will provide an overview of all state legislative
action directed towards increasing uptake
of the HPV vaccine, including what types of
policies have been enacted, examples of leg-
islative language used, and individual state
case studies.
School-based vaccination programs have
been used to increase uptake of the hep-
atitis B vaccine in places such as Denver,
Colorado
55
and Hawaii.
56
In addition to being recommended by the
ACIP, school-based vaccination programs
are recommended by the Community Pre-
ventive Services Task Force (CPSTF) “based
on strong evidence of effectiveness in in-
creasing vaccination rates, and in decreas-
ing rates of vaccine-preventable disease and
associated morbidity and mortality.”
57
Because the HPV vaccine is recommended
for all children at ages 11 or 12, targeting this
age group through schools could increase
HPV vaccine uptake. Studies in Texas and
-
creases in rates of HPV vaccination comple-
tion by using school based programs.
58,59
This
suggests that providing HPV vaccinations
at school may be an effective pathway to
increasing uptake, particularly in rural areas.
SCHOOL-BASED HEALTH CENTERS
Leveraging school-based health centers (SB-
HCs) to provide the HPV vaccine to students
attending co-located schools is also another
promising way to increase vaccine uptake. In
the United States, there are over 2000 SBHCs,
to mobile health centers and telehealth.
60
The services offered by these centers vary
depending on the community health profes-
sionals partnered with the centers.
SBHCs offer enhanced access to health
care, help reduce health care disparities
among populations, and provide for better
population health. California has approxi-
mately 277 SBHCs.
61
12
TABLE 1
Summary of Up-To-Date HPV Vaccination Rates and
Related Legislation
Many of the 18 states with higher rates of HPV vaccine uptake than California have enacted
legislation or regulations to support HPV vaccination. The following table summarizes the
policies that have supported HPV vaccination in these states as of February 2022.
#
Jurisdiction
HPV Up-
to-Date
Vaccination
Rate (%)
Summary
1 Rhode Island 83.0
Funding
Rhode Island General Laws § 23-1-44 establishes an
immunization program that covers the cost of vaccines
recommended by the ACIP, including the HPV vaccine.
Administrative Mandate
216-RICR-30-05-3.5.2 requires children have at least
one dose of the HPV vaccine before 7th grade, and the
completed series by 9th grade.
2 Hawaii 73.9
Administrative Mandate
Hawaii Administrative Rules Title 11 Ch. 157 requires HPV
vaccination prior to 7th grade attendance.
3 Massachusetts 73.4
Funding
M.G.L. Ch. 111 § 24N establishes the Vaccine Purchase Trust
Fund, which provides all federally recommended pediatric
vaccines including HPV.
4
District of
Columbia
72.3
Legislative Mandate
D.C. Code § 7–1651.04 requires vaccination for students
entering 6th grade.
5 South Dakota 71.5 None
6 Vermont 70.5 None
7 North Dakota 70.3
Education
N.D. Cent. Code Ann. § 23-01-33 provides funding for
distribution of educational materials on HPV and the HPV
vaccine.
8 Minnesota 69.2 None
9 New Hampshire 68.8
Funding
N.H. Rev. Stat. § 126-Q creates funding for NHIP, a program
that provides all recommended vaccines for children
through age 18 at no cost. HPV is included in this program.
13
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
#
Jurisdiction
HPV Up-
to-Date
Vaccination
Rate (%)
Summary
10 New York 68.1 None
11 Pennsylvania 67.1 None
12 Connecticut 66.9 None
13 Maryland 66.8
Funding
Md. Code Regs. 10.09.58.05 establishes the HPV vaccine
as a covered service under the Maryland Department of
Health’s Family Planning Program.
14 Colorado 66.4
Funding
2019 Colo. Rev. Stat. § 25-4-2503 provides funding support
for local public health agencies and FQHCs to administer
cervical cancer vaccinations.
Education
2019 Colo. Rev. Stat. § 25-4-2504 establishes a public
campaign for cervical cancer awareness. the cervical
cancer immunization fund.
15 Nebraska 64.8 None
16 Maine 63.5
Funding
22 M.R.S.A. § 1066 establishes the Universal Childhood
Immunization Program, which includes coverage of the
HPV vaccine free of charge for children ages 9-18.
17 Delaware 63.2 None
18 Illinois 63.1
Education
Illinois Senate Bill 2866 (2017) provides all students
entering sixth grade and their parents or legal guardians
written information about the link between HPV and
certain types of cancers.
Funding
20 Ill. Comp. Stat. Ann. 2310/2310-617 directs the
Department of Public Health to administer a program
for no-cost coverage of the HPV vaccine for all Illinois
residents under the age of 18.
14
-
fore the child enters sixth grade.
68
Like D.C.,
Virginia allows liberal opt-out options for
parents who object to the vaccine, whether
based on religious objections, a physician
or nurse practitioner statement that the
administration of the vaccine would be
detrimental to the health of the child, or if
the “parent or guardian, at the parent’s or
guardian’s sole discretion, may elect for the
parent’s or guardian’s child not to receive
the human papillomavirus vaccine after
having reviewed materials describing the
link between the human papillomavirus and
cervical cancer approved for such use by the
Board.” The Virginia mandate applies only to
females.
Despite having liberal opt-out provisions,
D.C. has achieved a rate of HPV vaccine up-
take well above the national average, with
72.3% of adolescents age 13–17 up to date
in 2020.
69
Meanwhile, although Virginia’s
vaccine uptake among adolescent females
exceeded the national average in 2020, a
comparatively low uptake among adoles-
cent males has caused the state’s overall
HPV vaccine uptake to fall below the nation-
al average.
70
OTHER STATE LEGISLATIVE
ACTION
Outside of a legislative or administrative
mandate, HPV vaccine-related legislation
largely falls into three categories: (1) edu-
cation campaigns; (2) funding or coverage
provisions; and (3) taskforce creation.
Illinois, Indiana, Iowa, Louisiana, Michigan,
Missouri, New Jersey, North Carolina, South
Carolina, Texas, Virginia, Washington, and
the District of Columbia have all passed laws
OVERVIEW OF MANDATES
Four jurisdictions currently require the HPV
vaccine for school attendance: Hawaii, Rho-
de Island, Virginia, and the District of Colum-
bia (D.C.). Of these four mandates, two are
legislative (Virginia and D.C.), while Rhode
Island and Hawaii both have administrative
mandates, discussed later in this toolkit.
In 2007, D.C. and Virginia, alongside 23 states
introduced legislation to mandate the HPV
vaccine for school-aged children.
65
Virginia
and D.C. were the only jurisdictions that suc-
cessfully enacted school-based mandates
that year. D.C. Code §7-1651.04 (2007) pro-
vides that “the parent or legal guardian of a
time at a school in the District of Columbia
the child had received the HPV vaccine,”
-
ceived the vaccine in compliance with one
of the three legislative exceptions. The D.C.
mandate allows children to be exempted if
the vaccination would violate their or their
parents’ religious belief, the child’s physician
inadvisable for that child, or “the parent or
legal guardian, at his or her discretion, has
elected to opt out of the HPV vaccination
program, for any reason . . .”
66
Although the
initial mandate only applied to female stu-
dents, § 7-1651.04(a)(3) (2007) extends “the
HPV vaccination program requirements to
males, consistent with standards set forth by
the CDC.”
67
When the CDC expanded HPV
vaccine recommendations to include males
at age 11 or 12, the D.C. mandate extended to
males as well.
Virginia Code § 32.1-46(A)(12) mandates
three doses of the HPV vaccine for females,
15
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
all passed laws aimed at easing the cost of
the HPV vaccine, either by providing state
funding or mandating that insurers cover
the cost of the vaccine.
72
Colorado, Illinois, Indiana, North Dakota,
Texas, and the District of Columbia have all
passed laws creating taskforces, commit-
tees, or studies to create recommendations
for the HPV vaccine.
73
promoting education on the HPV vaccine,
including measures such as mandates that
schools distribute information on the HPV
vaccine to parents and children and creation
of state-funded awareness campaigns.
71
Alaska, Colorado, Illinois, Louisiana, Maine,
Maryland, Massachusetts, Mississippi, Ne-
vada, New Hampshire, New Mexico, Ohio,
Oklahoma, Oregon, and West Virginia have
Figure 4
United States Map of Enacted HPV-Related
Mandates and Legislation
Legislation is one promising pathway to support increased HPV vaccine uptake. Many
states have enacted legislation related to the funding, study, or education of patients
related to the HPV vaccine, while relatively few have more stringent mandates.
Legend
States and
Territories with
HPV Vaccine
Mandate
States with
other enacted
HPV Legislation
States with
both
D.C.
RI
16
State Administrative
Action
Rather than pursuing legislative or execu-
tive action, Rhode Island and Hawaii have
targeted HPV through administrative ac-
tion. Rhode Island used legislation to vest
power in the Director of Health to promul-
gate immunization regulations. Pursuant
to these laws, 216-RICR-30-05-3.5.2 requires
the HPV vaccine for all school age children.
Hawaii’s mandate for all students in grades
seven through twelve to receive the vaccine
is similarly promulgated through an admin-
istrative rule from the state Department of
Health and Human Services.
79
Notably, both
the Rhode Island regulation and the Hawaii
administrative rule offer fewer exemption
categories than the D.C. and Virginia legisla-
tive mandates. They allow exemptions only
for religious objection or proof from a med-
ical professional that the student should be
exempt for medical reasons, limiting the
extent to which parents and guardians are
permitted to refuse the vaccine on their
child’s behalf.
In California, executive
action has been used to
successfully require and
recommend a number
of vaccinations for
college entry.
State Executive Action
Another possible pathway to increase rates
of completion of the HPV vaccine is through
state-level executive action.
In 2007, the year after the HPV vaccine was
-
tween the ages of 11 and 12,
74
Governor Rick
Perry of Texas issued Executive Order RP65
mandating the vaccine for females prior to
admission to the sixth grade.
75
The executive
order was overturned within months by the
Texas House of Representatives through a
vote of 118 to 23.
76
Although Governor Perry
defended his position initially, he revised his
stance during his presidential campaign in
2011, highlighting the politicized treatment
of the HPV vaccine.
77
Since Governor Perry’s
executive order was overturned in 2007,
no other state executive has pursued an
increase in HPV vaccine uptake through
executive action.
Generally, however, state executive action
has been used to promote vaccination
requirements. For example, in California,
executive action has been used to success-
fully require and recommend a number of
vaccinations for college entry. In 2019, Exec-
utive Order 803 updated the immunization
requirements for attendance at California
State University campuses; the Executive
Order tracked the California Department
of Health’s list of vaccines that should be
required, which does not currently include
HPV.
78
17
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
Other Points of Access:
Pharmacists and Dentists
Another potential pathway to increasing up-
take of the HPV vaccine is to increase points
of access to receive the vaccine. This method
may be particularly useful in reaching rural
populations, where access to physicians
may be limited.
Currently, 22 states allow pharmacists to
give HPV vaccines to patients between the
age of 11 and 12, but nine of those states
83
Cal-
ifornia is one of only two states, along with
Idaho, that allows pharmacists to administer
the HPV vaccine without a prescription or
standing order.
84
One method of increasing
uptake would be to promote vaccination
at pharmacies, though administrative bur-
programs may be a barrier for interested
pharmacies.
point of access with both the tools to admin-
ister vaccines and an interest in protecting
patient populations from HPV and associ-
ated cancers. In 2018, the American Dental
Association adopted a policy that urged
dentists to support the use and adminis-
tration of the HPV vaccine in response to
growing rates of HPV-related oropharyngeal
cancers.
85
In 2019, Oregon passed a law that
added the prescription and administration
of vaccines into a dentist’s scope of practice,
86
Practitioner Focus
Communication between healthcare pro-
viders and patients is one of the strongest
predictors of HPV vaccination.
80
One prom-
ising approach to increase uptake of the
HPV vaccine is to focus on provider-patient
interactions and to give providers the best
tools to educate their patients on the HPV
vaccine. Conversations between medical
professionals and patients or patients’ par-
ents and guardians can help emphasize the
importance of the HPV vaccine as a cancer
prevention tool. This may serve to combat
the stigma brought on by the HPV vaccine’s
historical association with sexually transmit-
ted disease.
To aid providers in navigating these interac-
tions, the CDC published “Top 10 Tips for HPV
Vaccination Success.”
81
Among these tips for
providers, the CDC recommends bundling
the HPV vaccine with other vaccination
recommendations, and emphasizing vacci-
nation against HPV-related cancers — not
just HPV.
Another useful resource for healthcare pro-
viders counseling patients and parents on
the HPV vaccine is the “HPV Vaccine Myth
Busting for Health Care Providers Social Me-
dia Toolkit,” published by the George Wash-
ington University Cancer Center. This toolkit
offers providers tips on social media usage
to promote awareness of the HPV vaccine
and best practices for provider communica-
tion about the HPV vaccine.
82
18
Many states have focused on provider outreach in order to increase vaccination rates
in their states. For example, the District of Columbia (which has one of the highest
vaccine rates in the country despite having one of the least restrictive mandates) has
utilized trainings and conferences to ensure providers give strong recommendations
for the HPV vaccine.
87
the Massachusetts Chapter of the American Academy of Pediatrics (MCAAP). The
MCAAP has a Vaccination Initiative that provides resources for providers, patients,
and parents on HPV and other childhood vaccines, with a current emphasis on vaccine
catch-up programs.
88
Figure 5
Spotlight on the States
MASSACHUSETTS
Vaccination Initiative
and catch up programs
that provide resources
to providers, patients,
and parents
WASHINGTON D.C.
Utilizes trainings and
conferences to ensure
providers give strong
recommendations for
the HPV vaccine
19
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
A 2012 study looked into the feasibility of a
“catch up” vaccination program for college
students and found that knowledge of the
vaccine was moderate, and especially weak
regarding its use as a cancer-prevention
tool.
90
The same study found that 71% of stu-
dent participants were eligible and willing
to receive school-based HPV vaccines at col-
lege. These data are encouraging and show
that a college-based vaccination program
COVID-19
In October 2021, California signaled its intent
to require COVID-19 vaccination for public
school attendance once the FDA has fully
approved the vaccines for children.
91
While
it remains to be seen how the state intends
to enact the requirement, its chosen levers
may be instructive for HPV vaccine path-
ways in California. Both Louisiana and the
District of Columbia have announced similar
requirements pending FDA approval.
92
The CDC has warned that disruptions to
childhood vaccination schedules as a result
of the COVID-19 pandemic may create sig-
outbreaks among children and adolescents
as schools resume in-person learning.
93
Al-
though pediatric vaccination has returned
to pre-pandemic levels in recent months,
for its steep decline in early 2020.
94
As re-
covery from COVID-19 continues, states will
have to contend both with the delays in care
and the pervasive vaccine hesitancy that the
pandemic has left in its wake.
Allowing pharmacists and dentists to ad-
minister the HPV vaccine could increase
rates of uptake of the vaccine by reducing
the barriers to access. Patients who visit
a general practitioner infrequently may
have more regular contact with a dentist
or pharmacist. Furthermore, for patients
and their guardians who may be resistant
to the vaccine as a result of its association
with sexually-transmitted disease, conver-
sations with a dentist regarding the risk of
oropharyngeal cancer may serve to under-
line the importance of the HPV vaccine as a
cancer prevention tool.
Targeting the College
Population
With vaccination rates for target populations
lower than desired by many health profession-
als, targeting college-age students presents
an opportunity to impact total rates of HPV
vaccine uptake and prevent HPV-related can-
cers.
89
Although vaccination is recommended
at the age of 11 or 12 and the vaccine is most
effective when administered before any sex-
ual activity, vaccination is still recommended
for everyone up to age 26 because there are
multiple strains of HPV to protect against.
Targeting college-age students
presents an opportunity to
impact total rates of HPV
vaccine uptake and prevent
HPV-related cancers.
20
will require coordinated, multi-pronged ap-
proaches that give careful consideration to
the needs and context of target populations.
State policy-makers, educational institu-
tions, and healthcare providers of all kinds
have important roles to play in promoting
uptake and improving health outcomes. It is
our hope that this resource may serve as a
tool in occupying those roles effectively.
Conclusion
at reducing rates of HPV and associated
cancers, uptake remains low across the
United States. Low demand, inadequate
provider recommendations, limited indi-
sexuality-related stigma have all contribut-
ed to this problem. Faced with an array of
challenges, no one policy pathway will be
the solution: increasing HPV vaccine uptake
21
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
21
Resource Library
HPV Vaccination for Cancer Prevention: Progress, Opportuni-
ties, and a Renewed Call to Action, https://prescancerpanel.cancer.gov/report/hpvupdate/
In 2018, the President’s Cancer Panel published a report designed to provide an overview of
increase uptake of the HPV vaccine. This resource includes information on efforts related to
the HPV Vaccine and sets four new goals moving forward.
, https://cahpvroundtable.org/
The California HPV Vaccination is a statewide coalition of various stakeholders, including
members that represent immunization, cancer control, academia, community organizations,
state and local agencies, among others, who work together to prevent HPV-associated can-
cers and pre-cancers by increasing the HPV vaccination among the recommended age group.
HPV Vaccination Project, https://www.une.edu/
ahec/hpv-vaccination-project
The Maine Area Health Education Center received funding from the CDC to provide continu-
ing education to health professionals about the HPV vaccine. This resource includes Clinician
FAQs, recommendations for improving general practice related to the HPV Vaccine, HPV Fact
Sheets, and documents with tips on how to talk to parents.
https://www.hpv-cvc.org/
This resource provides downloadable visual messaging tools, including patient brochures,
bulletin boards, slide sets, and pre-visit patient questionnaires that providers can use to
increase uptake ovf the HPV vaccine.
Mission: HPV Cancer Free, https://www.cancer.org/healthy/
hpv-vaccine.html
This resource focuses on the HPV vaccine as a cancer-prevention tool and includes
against cancer.
https://hpvroundtable.org/
The National HPV Vaccination Roundtable is a coalition of organizations across the country
that work at the intersection of immunization and cancer prevention.
“We Need Access”: Ending Preventable Deaths from Cervical Cancer in Rural Georgia,
-
This resource documents racial disparity in access comprehensive cervical cancer treatment
and makes recommendations for how state and federal policies can better address the
healthcare needs of rural Black women.
22
There are many different paths available to stakeholders looking to increase completion
rates of the HPV vaccine in California. Different states, countries, and advocacy groups have
increased uptake of the vaccine through legislative action, regulatory action, school-based
vaccination programs, and aiding providers in their direct-to-patient outreach. Based on Cali-
Appendix A
A Review of Pathways for California
Current California Public University Immunization Requirements
California has two public university systems: California State University (CSU) and
the University of California (UC), which require a number of vaccinations, both by
statute and through the California Department of Public Health (CDPH).
CSU, with 23 campuses, requires that incoming students are vaccinated for
hepatitis B (HBV) in accordance with the California Health and Safety Code.
95
The University of California, with 10 campuses, is exempted from the mandate
unless the Regents of the University of California expressly adopt the provision,
and they have not.
96
CSU has a series of required immunizations beyond the statutorily mandated
HBV and meningococcal vaccines. In March of 2019, Executive Order 803 (EO)
was issued on immunization requirements for CSU campuses, which are
based on CDPH's immunization and screening recommendations for college
students.
97
HPV is not required by this order, but is listed under recommend-
ed immunizations and screenings for people through age 26.
98
This designa-
tion means that students are “strongly encouraged” to obtain the service and
that students are directed to discuss the service with a health care provider.
UC campuses, although not covered by the EO, also elect to follow CDPH
recommendations.
99
The current UC Immunization Policy requires incoming
students to obtain the vaccinations recommended by CDPH for those diseases
that can be passed on to others by respiratory transmission.
100
All UC campuses
require HBV, TB, measles, mumps and rubella, meningococcus, varicella, and
tetanus, diphtheria and pertussis.
101
Like CSU, UC also strongly recommends
the HPV vaccine but does not require it.
102
23
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
vaccine uptake in rural communities. An-
other opportunity to increase access to the
HPV vaccine would be to pass legislation or
promulgate regulations allowing dentists to
administer the HPV vaccine.
PROVIDER OUTREACH
A low-cost pathway to increasing uptake of
the HPV vaccine in California would be to
increase resources and support for provider
direct-to-patient outreach. As stated in this
toolkit, communication between healthcare
providers and patients is one of the strong-
est predictors of HPV vaccination.
106
Effective
provider-patient communication is likely to
prove complementary to any chosen policy
pathway.
SCHOOL-BASED VACCINATION
PROGRAMS
School-based vaccination programs have
seen great success in other countries and in
pilot programs, like the SBHCs in Denver, in
increasing uptake of the HPV vaccine.
Not only are these programs demonstrably
successful and recommended by the ACIP,
but they also help to address disparities
among populations that arise from a lack of
access to healthcare. Disparities in cervical
cancer among racial groups and between
rural and urban populations have been
observed. Widespread school-based vacci-
nation programs aimed at increasing access
and uptake of the HPV vaccine could not
only help prevent cancer, but also combat
these disparities.
CDPH ACTION
Although the HPV vaccine is recommended
as young as 11, the CDC recommends the
vaccine through the age of 26 (with shared
clinical decision-making for people aged 27
to 45 years).
103
College students may have al-
ready been exposed to some strains of HPV,
but because there are many strains of HPV
the vaccine can still be a helpful cancer pre-
vention tool for that population. Targeting
college students is a step in the right direc-
tion in order to increase rates of completion
for the population as a whole.
Because CSU is mandated to follow CDPH
recommendations and UC has elected to
follow the current UC Immunization Policy,
one key pathway to increase uptake of the
HPV vaccine in California would be for CDPH
to update its current recommendations to
include the HPV vaccine.
LEGISLATIVE OR REGULATORY
MANDATE
State law can mandate, or state agencies
may regulate, receipt of the HPV vaccine for
school entry. Of the four jurisdictions that
have such mandates, three are in the top
of the HPV vaccine.
104
INCREASED ACCESS POINTS
California already allows pharmacists to
administer the HPV vaccine; however, many
do not do so.
105
Investigating barriers to
pharmacists administering the vaccine may
be instructive, particularly for increasing
24
The following table represents data collected and analyzed by the California HPV Vaccination
Roundtable’s Using and Improving HPV Vaccination Data Workgroup (Data Workgroup).
The Data Workgroup used base data from the California Cancer Registry (CCR). To address
data suppression in smaller counties, county groupings were used where there were fewer
than 11 total HPV-attributable cases.
107
Appendix B
California Age-Adjusted Rate of HPV-
Attributable Cancers by County
Credit: Assessment of Human Papillomavirus (HPV) Attributable Cancers and Vaccination Rates in California,
(2020).
County
Age-adjusted rate
of HPV-attributable
cancers (per 100,000)
All California 8.6
Alameda 7.5
Alpine, Amador, and Calaveras 9.8
Butte 10.9
Colusa, Glenn, Tehama 11.9
Contra Costa 7.8
Del Norte, Humboldt 11.2
El Dorado 9.6
Fresno 8
Imperial 7.7
Inyo, Mono 9.2
Kern 9.4
Kings 9.7
Lake 11.5
Lassen, Modoc, Plumas 10.2
Los Angeles 8.2
Madera 8.6
Marin 10.4
Mariposa, Tuolumne 9.8
Mendocino 9.8
Merced 8.2
Monterey 8.5
Napa 10.3
Nevada 7.8
County
Age-adjusted rate
of HPV-attributable
cancers (per 100,000)
Orange 8.1
Placer 9.7
Riverside 9.8
Sacramento 10.2
San Benito 9.6
San Bernardino 9.3
San Diego 9.2
San Francisco 9
San Joaquin 9.2
San Luis Obispo 9
San Mateo 7.1
Santa Barbara 8.5
Santa Clara 6.2
Santa Cruz 9.5
Shasta 11.5
Sierra, Yuba 8.9
Siskiyou, Trinity 10
Solano 8.5
Sonoma 9.9
Stanislaus 8.7
Sutter 9.4
Tulare 10.4
Ventura 8.9
Yolo 8.3
25
HPV VACCINE POLICY LANDSCAPE: Public Health Strategies
The following table ranks states by up-to-date HPV vaccination rates among adolescents
aged 13–17 years in 2020 based on data collected by the National Immunization Survey.
108
Participants are considered up-to-date when they have received the recommended doses
of the HPV vaccine, either two doses if they received the vaccine before they were 15 or three
doses if they receive the vaccine after the age of 15.
Appendix C
Rate of Up-to-Date HPV Vaccination
by State
Jurisdiction
Rate of Up-
to-date HPV
Vaccination
95%
Condence
Interval
United States 58.6 57.3–60.0
1 Rhode Island 83.0 76.9–87.7
2 Hawaii 73.9 67.6–79.4
3 Massachusetts 73.4 67.6–78.5
4 District of Columbia 72.3 65.1–78.5
5 South Dakota 71.5 65.4–76.9
6 Vermont 70.5 64.5–75.8
7 North Dakota 70.3 64.0–76.0
8 Minnesota 69.2 62.5–75.1
9 New Hampshire 68.8 63.1–73.9
10 New York 68.1 63.5–72.4
11 Pennsylvania 67.1 61.2–72.5
12 Connecticut 66.9 60.5–72.7
13 Maryland 66.8 61.9–71.3
14 Colorado 66.4 59.9–72.4
15 Nebraska 64.8 58.9–70.3
16 Maine 63.5 57.5–69.1
17 Delaware 63.2 56.6–69.2
18 Illinois 63.1 57.9–68.1
19 California 62.3 55.4–68.8
20 Oregon 61.6 55.0–67.8
21 Wisconsin 61.5 54.4–68.0
22 Michigan 61.3 55.1–67.2
23 North Carolina 60.7 53.4–67.5
24 Louisiana 60.4 53.6–66.8
25 Iowa 60.3 53.4–66.8
Jurisdiction
Rate of Up-
to-date HPV
Vaccination
95%
Condence
Interval
26 New Jersey 59.7 53.1–66.0
27 New Mexico 59.2 53.0–65.1
28 Washington 59.0 52.2–65.5
29 Virginia 56.4 50.0–62.5
30 Kentucky 55.7 48.3–62.9
31 Alaska 54.9 47.8–61.8
32 Georgia 54.9 47.7–62.0
33 Texas 54.9 49.9–59.9
34 Idaho 54.5 47.9–61.0
35 Montana 54.4 47.6–61.0
36 Missouri 53.6 46.9–60.1
37 Indiana 53.4 46.4–60.2
38 Kansas 53.3 46.9–59.6
39 Ohio 53.2 46.4–59.8
40 Alabama 52.9 46.3–59.4
41 Tennessee 52.9 46.3–59.4
42 Florida 51.6 44.4–58.7
43 Arizona 51.4 45.0–57.7
44 Nevada 50.1 43.4–56.8
45 Arkansas 49.6 42.6–56.5
46 South Carolina 47.0 40.2–53.8
47 Oklahoma 45.8 39.4–52.3
48 Utah 45.0 38.1–52.1
49 Wyoming 44.8 38.3–51.4
50
West Virginia 43.4 37.1–49.8
51 Mississippi 31.9 25.9–38.5
* Adolescents (N = 20,163) in the 2020 NIS–Teen were born January 2002 through February 2008.
26
ENDNOTES
1. Sexually Transmitted Infections
Prevalence, Incidence, and Cost Es-
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for Disease Control anD Prevention,
https://perma.cc/N82M-HUNL
(last updated Jan, 25, 2021); Human
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C
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(last updated Jul. 23, 2021).
2. Cervical cancer is the “[fourth] most
common cancer among women
worldwide, and currently the 14
th
cause of cancer deaths among wom-
en in the U.S.” Jacqueline Hirth,
Disparities in HPV vaccination rates
and HPV prevalence in the United
States: a Review of the Literature,
15(1) H
uman vaCCines & immunotHera-
PeutiCs 146, 146–155 (2019). CHLPI
recognizes that people of any gender
may have cervical cancer, but uses
the language of the source in this
footnote to ensure accurate report-
ing of the corresponding statistic.
3. National Vaccine Advisory Com-
mittee, Overcoming Barriers to Low
HPV Vaccine Uptake in the United
States: Recommendations from the
National Vaccine Advisory Commit-
tee, 131 P
ubliC HealtH rePorts 17,
17–24 (2016).
4. How Many Cancers Are Linked with
HPV Each Year?, C
enters for Disease
C
ontrol anD Prevention, https://per-
ma.cc/3C2S-UAH6 (last updated
Dec. 13, 2021).
5. This includes: costs of cervical
cancer screening and follow-up and
the treatment costs of cervical, anal,
vaginal, vulvar, penile, and oropha-
ryngeal cancers, as well as genital
warts and RRP. HPV-Associated
Diseases, P
resiDent’s CanCer Panel
a
nnual rePort 2012-2013, https://
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6. Reasons to get HPV Vaccine, C
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https://perma.cc/64VL-RJ68 (last
updated Nov. 10, 2021).
7. How Cancer Treatments Can Affect
Fertility in Women, a
meriCan CanCer
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oCiety, https://perma.cc/J6DR-
HW4W (last updated Feb. 6, 2020).
8. Assessment of Human Papilloma-
virus (HPV) Attributable Cancers
and Vaccination Rates in California,
C
alifornia HPv vaCCination rounDtable
(2020).
9. Howard LeWine, M.D., HPV trans-
mission during oral sex a growing
cause of mouth and throat cancer,
(June 4, 2013) H
arvarD HealtH blog,
https://perma.cc/AWG2-QL5P.
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11. HPV: Head, Neck and Oral Cancers,
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12. HPV (human papillomavirus), fooD
anD Drug aDministration, https://
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13. The HPV vaccine was initially
“licensed for use among females
aged 9-26 years for prevention
of [HPV-related] cervical cancer,
cervical cancer precursors, vaginal
and vulvar cancer precursors, and
anogenital warts.” Lauri E. Mar-
kowitz, et al., Quadrivalent Human
Papillomavirus Vaccine: Recommen-
dations of the Advisory Committee
on Immunization Practices, 56(RR-2)
m
orbiDity anD mortality Weekly re-
Port 1, 2 (2007) (citation omitted).
14. Elissa Meites et al., Human Papil-
lomavirus Vaccination for Adults:
Updated Recommendations of the
Advisory Committee on Immuniza-
tion Practices, 68(32) m
orbiDity anD
m
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8, 2020), https://perma.cc/3Z9Z-
4TWP.
15. Id.
16. The HPV Vaccine: Access and Use
in the U.S., k
aiser family founDation,
(July 12, 2021), https://perma.cc/
GFR9-7FW6.
17. Id.
18. Meites et al., supra note 14.
19. HPV Vaccine: State Legislation and
Statutes, n
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l
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20. Id.
21. Richard Knox, HPV Vaccine: The
Science Behind the Controversy, nPr
(Sept. 19, 2011), https://perma.cc/
T5UQ-QQD9.
22. Id.
23. Id.
24. Human Papillomavirus (HPV)—HPV
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HL2J-LYSW (last updated Jul. 23,
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25. Meites et al., supra note 14.
26. Increase the Proportion of Ado-
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27. National Center for Immunization
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28. Id.
29. Id.
30. Id.
31. Healthy People 2030, supra note 26.
32. See, e.g., Kathleen B. Cartmell, et al.,
Barriers, facilitators, and potential
strategies for increasing HPV: A
statewide assessment to inform
action, 5 P
aPillomavirus researCH
21 (2017); Overcoming Barriers
to Low HPV Vaccine Uptake in the
United States: Recommendations
from the National Vaccine Advisory
Committee, 131 P
ubliC HealtH rePorts
17, 20 (2016); Dawn M. Holman,
et al., Barriers to Human Papillo-
mavirus Vaccination Among US
Adolescents: A Systematic Review of
the Literature, 168 Jama P
eDiatriCs
76, 80 (2014).
33. See, e.g., Overcoming Barriers to
Low HPV Vaccine Uptake in the
United States: Recommendations
from the National Vaccine Advisory
Committee, 131 P
ubliC HealtH rePorts
17, 20 (2016); HPV Vaccine Com-
munication: Special Considerations
for a Unique Vaccine – 2016 Update,
W
orlD HealtH organization (2017).
34. See, e.g., Kimberly K. Walker, et al.,
USA Dental Health Providers’ Role
in HPV Vaccine Communication and
HPV-OPC Protection: a Systematic
Review, 15 H
uman vaCCines & immu-
notHeraPeutiCs 1863, 1863-64 (2019)
(noting that some individuals who
do not have contact with a general
health care provider, may instead
have contact with a dental health
provider leaving dental health
professionals with the opportunity
for primary ); Parth D. Shah, et al.,
Pharmacies Versus Doctors’ Oces
for Adolescent Vaccination, 36 v
aC-
Cine 3453 (2018) (noting that parents
may perceive pharmacies as provid-
ing better access to adolescent
vaccinations).
35. See, e.g., Ashley Ojeage, et al., Racial
Disparities in HPV-related Knowl-
edge, Attitudes, and Beliefs Among
African American and White Women
in the USA, 34 J
ournal of CanCer
e
DuCation 66, 66 (2019); Eric Adjei
Boakye, et al., Approaching a Decade
Since HPV Vaccine Licensure: Racial
and Gender Disparities in Knowledge
and Awareness of HPV and HPV Vac-
cine, 13 H
uman vaCCines & immunotHer-
aPeutiCs 2713, 2716 (2017); Amanda
Gelman, et al., Racial Disparities in
Awareness of the Human Papilloma-
virus, 20 J
ournal of Women’s HealtH
1165 (2011).
36. See, e.g., Kimberly R. McBridge &
Shipra Singh, Predictors of Adults’
Knowledge and Awareness of HPV,
HPV-Associated Cancers, and the
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