National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2017

Tanja Y. Walker, MPH; Laurie D. Elam-Evans, PhD; David Yankey, PhD; Lauri E. Markowitz, MD; Charnetta L. Williams, MD; Sarah A. Mbaeyi, MD; Benjamin Fredua, MS; Shannon Stokley, DrPH


Morbidity and Mortality Weekly Report. 2018;67(33):909-917. 

In This Article

Abstract and Introduction


The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of persons aged 11–12 years with human papillomavirus (HPV) vaccine, quadrivalent meningococcal conjugate vaccine (MenACWY), and tetanus and reduced diphtheria toxoids and acellular pertussis vaccine (Tdap). A booster dose of MenACWY is recommended at age 16 years,[1] and catch-up vaccination is recommended for hepatitis B vaccine (HepB), measles, mumps, and rubella vaccine (MMR), and varicella vaccine (VAR) for adolescents whose childhood vaccinations are not up to date (UTD).[1] ACIP also recommends that clinicians may administer a serogroup B meningococcal vaccine (MenB) series to adolescents and young adults aged 16–23 years, with a preferred age of 16–18 years.[2] To estimate U.S. adolescent vaccination coverage, CDC analyzed data from the 2017 National Immunization Survey–Teen (NIS-Teen) for 20,949 adolescents aged 13–17 years.* During 2016–2017, coverage increased for ≥1 dose of HPV vaccine (from 60.4% to 65.5%), ≥1 dose of MenACWY (82.2% to 85.1%), and ≥2 doses of MenACWY (39.1% to 44.3%). Coverage with Tdap remained stable at 88.7%. In 2017, 48.6% of adolescents were UTD with the HPV vaccine series (HPV UTD) compared with 43.4% in 2016. On-time vaccination (receipt of ≥2 or ≥3 doses of HPV vaccine by age 13 years) also increased. As in 2016, ≥1-dose HPV vaccination coverage was lower among adolescents living in nonmetropolitan statistical areas (MSAs) (59.3%) than among those living in MSA principal cities (70.1%).§ Although HPV vaccination initiation remains lower than coverage with MenACWY and Tdap, HPV vaccination coverage has increased an average of 5.1 percentage points annually since 2013, indicating that continued efforts to target unvaccinated teens and eliminate missed vaccination opportunities might lead to HPV vaccination coverage levels comparable to those of other routinely recommended adolescent vaccines.

NIS-Teen is an annual survey that estimates vaccination coverage among adolescents aged 13–17 years in the 50 states, the District of Columbia (DC), selected local areas, and territories. NIS-Teen is conducted among parents and guardians of eligible adolescents identified using a random-digit–dialed sample of landline and cellular telephone numbers.** Parents and guardians are interviewed by telephone about the sociodemographic characteristics of the adolescent and household. Contact information and consent to contact the teen's vaccination providers are requested. When more than one age-eligible adolescent lives in the household, one is randomly selected for participation. Vaccination providers identified during the interview are mailed a questionnaire requesting the vaccination history from the teen's medical record.†† Vaccination coverage estimates are based on provider-reported vaccination histories. This report summarizes national vaccination coverage for 20,949 adolescents (9,845 females [47%] and 11,104 males [53%]) aged 13–17 years with adequate provider data.§§

Data were weighted and analyzed to account for the complex sampling design of NIS-Teen. NIS-Teen methodology, including methods for weighting and synthesizing provider-reported vaccination histories, has been described previously.[3] T-tests were used to assess vaccination coverage differences between 2017 and 2016 and between demographic subgroups (i.e., age, health insurance status, MSA status, race/ethnicity, and poverty level). Weighted linear regression by survey year was used to estimate annual percentage point changes in coverage. Trends in HPV vaccination initiation and HPV UTD status by year of birth were assessed using combined data from 2016 and 2017 NIS-Teen; p-values <0.05 were considered statistically significant.

*Eligible participants were born during January 1999–February 2005. Tdap coverage represents receipt of ≥1 Tdap dose at age ≥10 years. MenACWY coverage represents receipt of the quadrivalent meningococcal conjugate vaccine or meningococcal vaccine of unknown type. MenB coverage represents receipt of at least 1 dose of either a 2-dose or 3-dose series, depending upon the vaccine brand. HPV vaccination coverage includes receipt of any HPV vaccine and does not distinguish between nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV) vaccines. Some adolescents might have received more than the 2 or 3 recommended HPV vaccine doses. Estimates for hepatitis B and MMR vaccines represent coverage based on catch up for adolescents who were not up-to-date with these vaccinations. Except as noted, coverage estimates for ≥1 and ≥2 varicella vaccine doses were obtained among adolescents with no history of varicella disease. Influenza vaccination coverage data are not included in this report but are available online at
Adolescents were considered to be HPV UTD if they had received ≥3 doses, or if all of the following applied: 1) they had received 2 doses; 2) the first dose was received before the 15th birthday; and 3) the interval between the first and second doses was ≥5 months minus 4 days, the absolute minimum interval between the first and second doses.
§MSA status was determined based on household reported city and county of residence, and status was grouped into three categories: MSA principal city, MSA nonprincipal city, and non-MSA. MSA and principal city were as defined by the U.S. Census Bureau ( Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.
The following local areas that received federal Section 317 immunization funds were sampled separately: Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas. Three local areas were oversampled (Dallas County, Texas, El Paso County, Texas, and Travis County, Texas). Three territories were sampled separately in 2017 (Guam, Puerto Rico, and the U.S. Virgin Islands). Because of the severity of 2017's hurricane season, survey operations in Puerto Rico and the U.S. Virgin Islands were suspended resulting in insufficient data for estimation of vaccination coverage.
**All identified cellular-telephone households were eligible for interview. Sampling weights were adjusted for dual-frame (landline and cellular telephone), nonresponse, noncoverage, and overlapping samples of mixed telephone users. A description of NIS-Teen dual-frame survey methodology and its effect on reported vaccination estimates is available at Starting in 2018, the landline telephone sample was dropped.
††For the telephone samples for the states and local areas, the overall Council of American Survey Research Organizations (CASRO) response rate was 25.7% (51.5% for the landline sample and 23.5% for the cellular-telephone sample). For adolescents with completed interviews, 48.1% had adequate provider data (53.6% landline sample, 47.1% cell sample). Among completed interviews with adequate provider data, 17% (3,572) were from the landline sample, and 83% (17,377) were from the cellular telephone sample. For Guam, the overall CASRO response rate was 31.3%. The CASRO response rate is the product of three other rates: 1) the resolution rate (the proportion of telephone numbers that can be identified as either for business or residence); 2) the screening rate (the proportion of qualified households that complete the screening process); and 3) the cooperation rate (the proportion of contacted eligible households for which a completed interview is obtained).
§§Adolescents from Guam (n = 382).