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

Disclosures

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

In This Article

Discussion

In 2017, adolescent vaccination coverage with ≥1 dose of HPV vaccine, ≥1 and ≥2 doses of MenACWY, ≥2 doses of MMR, and ≥2 doses of VAR increased, while coverage with ≥1 dose of Tdap and ≥3 doses of HepB remained high. This report includes the first U.S. estimates of ≥1-dose MenB coverage. Unlike MenACWY, MenB is not routinely recommended for all adolescents, and thus, the low vaccination coverage in adolescents aged 17 years (14.5%) is not unexpected.

In December 2016, a 2-dose HPV vaccine schedule was recommended for persons starting the series at age <15 years, based on data showing noninferior immunogenicity compared with 3 doses.[5] This schedule might encourage on-time initiation of the series and facilitate completion; however, it is too early to assess its impact on vaccination coverage. The 5.1 percentage point annual increase in series initiation among all adolescents since 2013 is encouraging. Moreover, on-time vaccination (series completion by age 13 years) has increased approximately four percentage points in each successive birth cohort. Despite these improvements, HPV vaccination initiation remains lower than coverage with Tdap and MenACWY, suggesting ongoing challenges to providing all three vaccines during the same visit. Efforts are under way to promote and improve on-time vaccination, including implementing a new combined Healthcare Effectiveness Data and Information Set measure for adolescent vaccines that assesses receipt of all three routinely recommended adolescent vaccines, including HPV vaccine series completion by age 13 years.[6]

HPV vaccine and MenACWY coverage in non-MSA areas remains lower than that in MSA areas. Disparities in coverage by MSA status were not observed for Tdap. Unlike persons living in urban settings, rural residents are less likely to have knowledge of HPV or be aware of HPV vaccine and its importance in cancer prevention.[7,8] The overall shortage of health care providers, especially pediatricians, in rural areas might partially explain the lower coverage among rural adolescents.[8,9] Health care providers in rural areas serve a broader population base and might be less familiar with adolescent vaccination recommendations. A study including adolescents and parents in rural Alabama identified provider education, better communication with parents and adolescents about the importance of HPV vaccination for preventing cancer, and a strong provider recommendation as being most influential in initiation of HPV vaccination.[7] Resources are available to facilitate discussion with adolescents and their parents about the importance of HPV vaccination (https://www.cdc.gov/hpv/). Further evaluation is needed to identify where teens are receiving Tdap in non-MSAs and better understand the barriers to providing HPV vaccine and MenACWY at these sites.

The findings in this report are subject to at least five limitations. First, the overall household response rate was 25.7% (landline = 51.5%; cell phone = 23.5%), and only 53.6% of landline-completed and 47.1% of cell phone–completed interviews included adequate provider data. Second, bias in estimates might remain after adjustment for household and provider nonresponse and phoneless households.¶¶¶ Weights have been adjusted for the increasing number of cell phone–only households over time. Nonresponse bias might change, which could affect comparisons of estimates between survey years. Third, estimates stratified by state/local area might be unreliable because of small sample sizes. Fourth, multiple statistical tests were conducted, and a small number might be significant because of chance alone. Finally, because NIS-Teen includes adolescents aged 13–17 years, data on receipt of MenACWY or MenB vaccine at age ≥18 years could not be collected; thus reported coverage with these vaccines might underestimate the proportion of adolescents receiving them.[1]

HPV vaccination initiation and completion continue to increase. Postintroduction monitoring studies have found reductions in cervical HPV infection, genital warts, and cervical precancers in the United States.[10] Protection against HPV-related cancers will continue to increase if adolescents and their parents are educated about the cancer prevention benefits of HPV vaccine and clinicians consistently recommend and simultaneously administer Tdap, MenACWY, and HPV vaccine at age 11–12 years.

¶¶¶In a sensitivity analysis of 2013 NIS-Teen data, including adjustments for incomplete sample frame, nonresponse bias, and incomplete ascertainment of vaccination status, estimates of Tdap, ≥1 dose MenACWY, and ≥1 dose HPV vaccine coverage, were estimated to be lower than actual values by 1–3 percentage points https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-TEEN-PUF16-DUG.pdf.

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