HPV Vaccine: State Legislation and Regulation



According to the Centers for Disease Control and Prevention (CDC), the human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Approximately 79 million Americans are infected with HPV. There is no cure for HPV, only treatment for related health problems. Most strains of the virus do not produce cancer or any symptoms and disappear on their own. However, HPV can cause genital warts and cancers of the mouth, throat, genitals and cervix. In the United States, nearly 14,000 women are diagnosed with cervical cancer each year and it kills over 4,000 women. This number is much smaller than countries that do not perform the Papanicolaou (Pap) test, a screening tool for cervical cancer. The American Cancer Society reports that, with HPV vaccination and screening, cervical cancer caused by HPV is preventable and usually treatable.  

Vaccine manufacturers brought the first HPV vaccine to the market in 2006; today, Gardasil 9 is the only HPV vaccine available in the United States. In 2006, CDC’s Advisory Committee on Immunization Practices (ACIP) first issued guidelines for girls between ages 11 and 12 to receive the HPV vaccine. In 2011, ACIP expanded those guidelines to recommend the vaccine for boys between ages 11 and 12 as a form of cancer prevention. In 2019, CDC’s August Morbidity and Mortality Weekly Report reiterated its recommendation for the routine vaccination of boys and girls between ages 11 and 12.

Although recommendations by ACIP provide guidance, school vaccination requirements are decided mostly by state legislatures. Some state legislatures have granted regulatory bodies such as the health department the power to require vaccinations, but the legislature controls vaccine selection authority and funding. 

The debate in states centers, in part, around school vaccination requirements. Some stakeholders who support access to the vaccine do not support a school mandate, citing concerns about the drug's cost, safety and parents' rights to refuse. Others may have moral objections related to a vaccination mandate for a sexually transmitted infection. Financing is another concern. If states make HPV vaccination mandatory, they must also address funding issues, including Medicaid and CHIP coverage, youth who are uninsured and whether to require coverage by insurance plans.

The HPV vaccine is available through the federal Vaccines for Children (VFC) program in all 50 states, Washington, D.C. and the eight U.S. territories. VFC provides vaccines for children ages nine to 18 who are covered by Medicaid, Alaskan-Native or Native American children, and some underinsured or uninsured children. 

Facts About HPV

  • HPV is the name of a group of viruses that includes more than 100 different types.
  • More HPV-associated cancers occur in the cervix than in any other site—about 12,000 per year.
  • About 34,000 potentially HPV-associated cancers of the head and neck (oral cavity and oropharynx) occur per year.

State Action

As of April 2020, at least four jurisdictions (Rhode Island, Virginia, Washington, D.C. and Puerto Rico) require HPV vaccination for school attendance. Hawaii will require the vaccine starting July 1, 2020.

States also address HPV prevention through a variety of efforts, either through the executive branch or the legislature. In 2006, the New Hampshire Department of Health and Human Services announced that it would provide the vaccine at no cost to girls under age 18. On February 2, 2007, Texas became the first state to issue a mandate—by executive order from the governor—that all girls entering the sixth grade receive the vaccine. A couple of months later, the legislature passed HB 1098 which overrode the executive order and the governor withheld his veto. In 2015, the Rhode Island Department of Health included HPV as a school entry requirement for seventh graders. The Department is authorized to do this without legislative approval.

Currently, 48 states, the District of Columbia and Puerto Rico allow pharmacists to administer the HPV vaccine. States set the minimum age for pharmacist HPV vaccination. The lowest limit is 10 years of age and the highest is 18 years or older.

The table below includes enacted legislation and regulation since 2006.

Enacted Legislation and Regulation Related to HPV Vaccination
State Summary
Hawaii In 2019, the Hawaii Department of Health amended Hawaii Administrative Rule 11-157 to require HPV vaccination for school attendance. The rule goes into effect July 1st, 2020.
North Carolina North Carolina House Bill 388 (2017) authorizes pharmacists to administer the HPV vaccine.
Illinois 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. Include boys 18 years and younger as an eligible individual for the vaccine.
Iowa Iowa Senate Bill 2322 (2017) authorizes pharmacists to administer the last two doses of the HPV vaccine to patients 11 years of age and older.
Hawaii Hawaii Senate Bill 514 (2017) authorizes pharmacists to administer the HPV vaccine.
Puerto Rico In 2017, Puerto Rico's department of health added the HPV vaccine requirement for students.
West Virginia West Virginia House Bill 2518 (2017) authorizes pharmacists to administer the HPV vaccine.
Rhode Island In 2015, Rhode Island’s Department of Health required that all students entering 7th grade receive the HPV vaccine and receive one dose a year until 9th grade.
Indiana  Indiana House Bill 1464 (2014) authorized pharmacists to administer the HPV vaccine.
Illinois Illinois Senate Bill 937 (2007) includes boys under 18 as eligible to receive the HPV vaccine at no cost.
Iowa In 2007, the Iowa Legislature enacted House Bill 611, requiring information HPV vaccination, screening and treatment be provided in health classes in public schools.
Maryland Maryland House Bill 1049 (2007) establishes the HPV Vaccine Subcommittee as a part of the Cervical Cancer Committee. Requires the subcommittee to issue a report to the committee.
Montana Montana Senate Bill 505 (2007) renews the cervical cancer task force and identifies strategies to educate the public on the availability and efficacy of the HPV vaccine.
Virginia In 2007, the Virginia General Assembly enacted House Bill 2035 to require HPV vaccination for girls entering 7th grade.
Washington, D.C. In 2007, the Council of the District of Columbia enacted D.C. Law 17-10 to require female students to receive the HPV vaccine before entering 7th grade.

Additional Resources