Original Article Impact of Virginia’s School-Entry Vaccine Mandate on Human Papillomavirus Vaccination Among 13–17-Year-Old Females Dudith Pierre-Victor, MPH, 1 Timothy F. Page, PhD, 2 Mary Jo Trepka, MD, MSPH, 1 Dionne P. Stephens, PhD, 3 Tan Li, PhD, 4 and Purnima Madhivanan, MBBS, MPH, PhD 1,5 Abstract Background: The link between human papillomavirus (HPV) and anogenital cancers is well established in the literature. Many states have passed laws requiring funding for HPV education or vaccination. Mandatory HPV vaccination policies have been considered and passed in several states; yet their effectiveness has not been evaluated. This study sought to assess the impact of Virginia’s HPV vaccine mandate for school-entry on HPV vaccine uptake among females aged 13–17 years. Methods: Data from the National Immunization Survey-Teen for the 2008–2012 period were used, and 3,203 adolescent females were included in the analysis. We performed difference-in-differences estimation and logistic regression with a policy and period interaction term. Virginia was considered the treatment state, and South Carolina and Tennessee were the comparison states to account for nonpolicy factors that may have affected vaccination rates during the time period considered in the analysis. Results: There was no evidence of an effect of Virginia’s HPV vaccine mandate for school-entry on vaccination rates or on physician vaccination recommendation using either the difference-by-differences analysis or the policy and period interaction term in the logistic regression. Physician recommendation was the factor most strongly associated with vaccination in the Virginia-South Carolina analysis (adjusted odds ratio [aOR] = 9.33; 95% con- fidence interval [CI]: 6.11–14.3) and in the Virginia-Tennessee analysis (aOR = 9.33; 95% CI: 6.11–14.3). Conclusion: Study findings suggest that Virginia’s HPV vaccine mandate for school-entry did not lead to a significant increase in HPV vaccination among adolescent females or physician recommendations. However, physician recommendation was the factor most strongly associated with vaccination. Keywords: human papillomavirus, vaccination, school-entry, mandate, effectiveness Introduction T he link between human papillomavirus (HPV) and oropharyngeal, penile, anal, vulvar, vaginal, and cervi- cal cancers is well estatblished. 1 To date, two HPV preven- tative vaccines have been licensed by the Food and Drug Administration. 2–4 The Advisory Committee on Immuniza- tion Practices (ACIP) recommends routine HPV immuniza- tion for 11–12-year-old adolescents. 5 HPV vaccination rates have increased in the United States, but they remain below Healthy People 2020s goal of 80%. 6 In 2014, among ado- lescent females aged 13–17 years, the overall HPV vaccine initiation rates were higher among non-Hispanic blacks (66.4%) and Hispanics (66.3%) compared to non-Hispanic whites (56.1%). 7 However, HPV vaccine completion rates were very low for all ethnic groups, with Hispanics having the highest rates (46.9%) followed by blacks (39.0%), whites (37.5%), and Asians (35.7%). 7 In January 2007, three bills (SB1230, HB2035, SB1914) were introduced in Virginia to include HPV vaccine among vaccines required for school. 8 As originally introduced, SB1230 and HB2035 would require that females received three doses of the HPV vaccine. 8 These bills did not include an opt-out option in addition to the regular exemptions for all other childhood vaccines. 8 The third bill, SB1914, would require females to receive three doses of the HPV vaccine, Departments of 1 Epidemiology, 2 Health Policy and Management, 4 Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, Florida. 3 Department of Psychology, College of Arts and Science, Florida International University, Miami, Florida. 5 Public Health Research Institute of India, Karnataka, India. JOURNAL OF WOMEN’S HEALTH Volume 00, Number 00, 2016 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2016.5869 1