National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2018

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

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(33):718-723.

Abstract and Introduction

Introduction

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of persons aged 11–12 years to protect against certain diseases, including human papillomavirus (HPV)–associated cancers, meningococcal disease, and pertussis.^[1] A booster dose of quadrivalent meningococcal conjugate vaccine (MenACWY) is recommended at age 16 years, and serogroup B meningococcal vaccine (MenB) may be administered to persons aged 16–23 years.^[1] To estimate vaccination coverage among adolescents in the United States, CDC analyzed data from the 2018 National Immunization Survey–Teen (NIS-Teen) which included 18,700 adolescents aged 13–17 years.* During 2017–2018, coverage with ≥1 dose of HPV vaccine increased from 65.5% to 68.1%, and the percentage of adolescents up-to-date^† with the HPV vaccine series increased from 48.6% to 51.1%, although the increases were only observed among males. Vaccination coverage increases were also observed for ≥1 MenACWY dose (from 85.1% to 86.6%) and ≥2 MenACWY doses (from 44.3% to 50.8%). Coverage with tetanus and reduced diphtheria toxoids and acellular pertussis vaccine (Tdap) remained stable at 89%. Disparities in coverage by metropolitan statistical area (MSA)^§ and health insurance status identified in previous years persisted.^[2] Coverage with ≥1 dose of HPV vaccine was higher among adolescents whose parents reported receiving a provider recommendation; however, prevalence of parents reporting receiving a recommendation for adolescent HPV vaccination varied by state (range = 60%–91%). Supporting providers to give strong recommendations and effectively address parental concerns remains a priority, especially in states and rural areas where provider recommendations were less commonly reported.

NIS-Teen is an annual survey that monitors vaccines received by adolescents aged 13–17 years in the 50 states, the District of Columbia, selected local areas, and U.S. territories.^¶ NIS-Teen is conducted among parents and guardians of eligible adolescents identified using a random-digit–dialed sample of cell phone numbers.** During the telephone interview, information is obtained on the sociodemographic characteristics of the teen and household, and contact information and consent to contact the teen's vaccination providers are requested. 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 presents vaccination coverage estimates for 18,700 adolescents (8,928 [48%] females and 9,772 [52%] males) aged 13–17 years with adequate provider data.^§§ The overall Council of American Survey Research Organizations response rate was 23.3%, and only 48.3% of adolescents with completed interviews had adequate provider data.

Previously described NIS-Teen methodology, including methods for weighting and synthesizing provider-reported vaccination histories (https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-TEEN-PUF17-DUG.pdf) was used. Beginning in 2018, NIS-Teen used a single-frame sample of cell phone lines. The landline telephone–sample frame that was used from 2006 through 2017 was dropped because of the declining number of landline-only households in the United States (https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/pubs-presentations/dual-to-single-frame-teen.html). Data were weighted and analyzed to account for the complex sampling design. T-tests were used to assess vaccination coverage differences by survey year (2018 compared with 2017) and between demographic subgroups. P-values <0.05 were considered statistically significant. SAS-callable SUDAAN (version 11; SAS Institute) was used to conduct all analyses.

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Abstract and Introduction
National Vaccination Coverage
Vaccination Coverage by Selected Characteristics
Provider Recommendation for HPV Vaccination
Discussion
References
Sidebar

* Eligible participants were born during January 2000–February 2006. Tdap represents coverage with ≥1 Tdap dose at age ≥10 years. MenACWY represents coverage with the quadrivalent meningococcal conjugate vaccine or meningococcal-unknown type vaccine. ACIP published Category B recommendations for the use of serogroup B meningococcal vaccine (MenB) in October 2015 (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6441a3.htm), with administration preferred at ages 16–18 years. HPV vaccination coverage represents receipt of any HPV vaccine and does not distinguish among 9-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV) vaccines. Some adolescents might have received more than the 2 or 3 recommended HPV vaccine doses. 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 https://www.cdc.gov/flu/fluvaxview/index.htm.
^† Adolescents were considered to be up to date with HPV vaccination 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 their 15th birthday; and 3) the difference between dates of first and second doses was ≥5 months minus 4 days, the absolute minimum interval between the first and second doses (https://www.cdc.gov/vaccines/programs/iis/cdsi.html).
^§ MSA status was determined based on household reported city and county of residence, and 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 (https://www.census.gov/programs-surveys/metro-micro.html). Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.
^¶ 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. Two local areas were oversampled: Hidalgo County, Texas and Tarrant County, Texas. Only one territory, Guam, was included as an estimation area in 2018.
** All identified cellular-telephone households were eligible for interview. Sampling weights were adjusted for single-frame (cellular telephone), nonresponse, and noncoverage. A description of NIS-Teen single-frame survey methodology and its effect on reported vaccination estimates is available at https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/pubs-presentations/dual-to-single-frame-teen.html.
^†† For the telephone samples for the states and local areas, the overall Council of American Survey Research Organizations (CASRO) response rate was 23.3%. For adolescents with completed interviews, 48.3% had adequate provider data. For Guam, the CASRO response rate was 22.4%, and 55.0% of adolescents with completed interviews had adequate provider data. In 2017, among completed interviews with adequate provider data, 17% (3,572) were from the landline sample, and 83% (17,377) were from the cell phone sample. 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 (309) were excluded from the national estimates.

Table 1. Estimated coverage with selected vaccines and doses among adolescents aged 13–17* years, by age at interview — National Immunization Survey–Teen (NIS-Teen), United States, 2018
Vaccine	Age at interview (yrs), % (95% CI)^†					Total
	13	14	15	16	17	2018	2017
	(n = 3,852)	(n = 3,875)	(n = 3,741)	(n = 3,751)	(n = 3,481)	(n = 18,700)	(n = 20,949)
Tdap^§ ≥1 dose	87.1 (85.0–89.0)	87.7 (85.4–89.7)	89.7 (87.8–91.4)	89.0 (87.1–90.6)	91.0 (89.5–92.4)^¶	88.9 (88.0–89.7)	88.7 (87.8–89.6)
MenACWY**
≥1 dose	86.3 (84.2–88.1)	86.2 (84.0–88.1)	86.1 (83.7–88.2)	86.3 (84.0–88.3)	88.1 (86.3–89.6)	86.6 (85.6–87.5)^††	85.1 (84.2–86.1)
≥2 doses^§§	NA	NA	NA	NA	50.8 (47.7–53.8)	50.8 (47.7–53.8)^††	44.3 (41.4–47.2)
HPV^¶¶ vaccine
All adolescents
UTD***	39.9 (37.0–42.9)	50.3 (47.3–53.2)^¶	54.0 (51.0–56.9)^¶	54.5 (51.5–57.5)^¶	57.5 (54.4–60.5)^¶	51.1 (49.8–52.5)^††	48.6 (47.3–49.9)
≥1 dose	62.6 (59.7–65.4)	66.9 (64.1–69.6)^¶	69.7 (66.9–72.3)^¶	71.2 (68.5–73.8)^¶	70.1 (67.3–72.8)^¶	68.1 (66.8–69.3)^††	65.5 (64.3–66.7)
Females
UTD	38.9 (35.0–42.9)	52.7 (48.5–56.8)^¶	54.7 (50.4–59.0)^¶	57.5 (53.3–61.6)^¶	66.0 (61.8–70.1)^¶	53.7 (51.8–55.6)	53.1 (51.2–55.0)
≥1 dose	61.1 (56.9–65.2)	68.6 (64.4–72.5)^¶	70.7 (66.5–74.5)^¶	73.5 (69.8–76.8)^¶	76.3 (72.2–80.0)^¶	69.9 (68.1–71.6)	68.6 (66.9–70.2)
Males
UTD	40.9 (36.5–45.3)	47.7 (43.6–51.8)^¶	53.2 (49.1–57.3)^¶	51.8 (47.5–56.1)^¶	50.0 (45.7–54.3)^¶	48.7 (46.8–50.6)^††	44.3 (42.6–46.0)
≥1 dose	64.0 (59.9–67.9)	65.1 (61.3–68.7)	68.7 (65.0–72.1)	69.2 (65.2–73.0)	64.7 (60.7–68.5)	66.3 (64.6–68.0)^††	62.6 (60.9–64.2)
MenB ≥1 dose ^†††	NA	NA	NA	NA	17.2 (14.9–19.9)	17.2 (14.9–19.9)	14.5 (12.3–17.1)
MMR ≥2 doses	93.5 (92.1–94.7)	93.0 (91.6–94.2)	91.8 (89.9–93.3)	90.5 (88.4–92.2)^¶	90.9 (89.2–92.4)^¶	91.9 (91.2–92.6)	92.1 (91.3–92.8)
Hepatitis B vaccine ≥3 doses	93.1 (91.5–94.5)	93.0 (91.5–94.3)	91.6 (89.1–93.5)	91.1 (89.3–92.6)	91.8 (90.1–93.2)	92.1 (91.3–92.8)	91.9 (91.1–92.6)
Varicella vaccine
History of varicella disease^§§§	9.8 (8.1–11.9)	10.3 (8.5–12.4)	11.8 (10.0–13.9)	12.4 (10.7–14.3)	15.0 (13.2–17.1)^¶	11.9 (11.0–12.7)^††	13.2 (12.3–14.2)
No history of varicella disease
≥1 dose vaccine	95.4 (94.2–96.5)	95.4 (94.2–96.3)	94.1 (92.1–95.6)	94.3 (92.7–95.5)	95.2 (93.9–96.3)	94.9 (94.3–95.4)	95.5 (94.8–96.1)
≥2 doses vaccine	92.1 (90.5–93.4)	91.3 (89.6–92.8)	89.8 (87.4–91.8)	86.6 (84.3–88.7)^¶	87.9 (85.4–90.1)^¶	89.6 (88.7–90.4)	88.6 (87.6–89.5)
History of varicella or ≥2 vaccine doses	92.9 (91.4–94.1)	92.2 (90.6–93.5)	91.0 (88.9–92.7)	88.3 (86.2–90.1)^¶	89.7 (87.5–91.6)^¶	90.8 (90.0–91.6)	90.1 (89.3–90.9)

Abbreviations: CI = confidence interval; HPV = human papillomavirus; MenACWY = quadrivalent meningococcal conjugate vaccine; MenB = serogroup B meningococcal vaccine; MMR = measles, mumps, and rubella vaccine; NA = not applicable; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine; UTD = up-to-date.
* Adolescents (N = 18,700) in the 2018 NIS-Teen were born January 2000–February 2006.
^† Estimates with 95% CIs >20 might be unreliable.
^§ Includes percentages receiving Tdap vaccine at age ≥10 years.
^¶ Statistically significant difference (p<0.05) in estimated vaccination coverage by age; reference group was adolescents aged 13 years.
** Includes percentages receiving MenACWY or meningococcal-unknown type vaccine.
^†† Statistically significant difference (p<0.05) compared with 2017 NIS-Teen estimates.
^§§ ≥2 doses of MenACWY or meningococcal-unknown type vaccine. Calculated only among adolescents who were aged 17 years at interview. Does not include adolescents who received 1 dose of MenACWY vaccine at age ≥16 years.
^¶¶ HPV vaccine, 9-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV). Percentages are reported among females and males combined (N = 18,700) and for females only (N = 8,928) and males only (N = 9,772).
*** HPV UTD includes those with ≥3 doses, and those with 2 doses when the first HPV vaccine dose was initiated at age <15 years, and there was at least 5 months minus 4 days between the first and second dose. This update to the HPV recommendation occurred in December 2016 (https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm).
^††† ≥1 dose of MenB. Calculated only among adolescents aged 17 years at interview. Administered based on individual clinical decision.
^§§§ By parent/guardian report or provider records.

Table 2. Estimated vaccination coverage with selected vaccines and doses among adolescents* aged 13–17 years by metropolitan statistical area ^† and health insurance status ^§ — National Immunization Survey–Teen (NIS-Teen), United States, 2018
Vaccine	MSA% (95% CI)^¶			Health insurance status % (95% CI)^¶
	Non-MSA	MSA nonprincipal city	MSA principal city	Private insurance only	Any Medicaid	Other insurance	Uninsured
	(n = 3,593)	(n = 7,543)	(n = 7,564)	(n = 10,404)	(n = 5,999)	(n = 1,516)	(n = 781)
Tdap ≥1 dose**	86.8 (84.8–88.5)	89.7 (88.4–90.8)	88.6 (87.1–89.9)	90.1 (89.0–91.2)	88.2 (86.6–89.6)^††	85.6 (82.3–88.3)^††	85.1 (80.7–88.6)^††
MenACWY^§§
≥1 dose	79.5 (77.3–81.6)^††	88.3 (87.1–89.4)	86.5 (84.7–88.0)	87.6 (86.4–88.8)	86.5 (84.8–88.0)	84.3 (81.1–87.0)^††	78.3 (72.7–83.0)^††
≥2 doses^¶¶	34.6 (28.5–41.2)^††	51.5 (46.7–56.2)	54.3 (49.7–58.9)	52.8 (48.6–56.9)	52.4 (46.9–57.8)	38.6 (30.0–48.0)^††	34.1 (21.6–49.4)^††
HPV* vaccine**
UTD^†††	40.7 (38.1–43.5)^††	49.1 (47.1–51.0)^††	56.1 (53.9–58.3)	50.2 (48.4–52.0)	55.7 (53.4–58.1)^††	45.1 (40.9–49.3)^††	35.5 (30.1–41.4)^††
≥1 dose	59.5 (56.8–62.2)^††	66.6 (64.8–68.4)^††	71.9 (69.8–73.9)	65.6 (63.8–67.3)	74.4 (72.3–76.3)^††	62.6 (58.5–66.5)	56.2 (50.1–62.2)^††
MMR ≥2 doses	90.1 (88.1–91.8)	92.3 (91.2–93.2)	92.0 (90.8–93.1)	92.8 (91.9–93.6)	92.0 (90.6–93.1)	90.1 (87.3–92.3)^††	84.2 (78.6–88.5)^††
Hepatitis B ≥3 vaccine doses	90.7 (88.8–92.4)	93.1 (92.1–94.0)^††	91.4 (89.9–92.6)	93.0 (91.9–93.9)	92.1 (90.8–93.3)	90.5 (87.8–92.6)	84.1 (78.5–88.4)^††
Varicella vaccine
History of varicella^§§§	15.0 (13.1–17.0)^††	10.6 (9.6–11.8)	12.4 (10.9–14.0)	9.8 (8.8–10.9)	13.4 (11.8–15.1)^††	13.8 (11.1–17.1)^††	20.4 (16.2–25.4)^††
Among adolescents with no history of varicella disease
≥1 varicella vaccine dose	93.4 (91.5–94.9)	95.0 (94.1–95.8)	95.1 (94.0–96.0)	95.7 (94.9–96.3)	94.4 (93.2–95.4)	93.3 (90.7–95.1)^††	91.3 (86.0–94.7)^††
≥2 varicella vaccine doses	86.4 (84.1–88.4)^††	89.8 (88.3–91.1)	90.2 (88.8–91.4)	90.5 (89.3–91.7)	89.4 (87.8–90.8)	86.7 (83.4–89.4)^††	83.8 (77.6–88.5)^††
History of varicella or ≥2 vaccine doses	88.5 (86.5–90.2)^††	90.9 (89.6–92.0)	91.4 (90.1–92.5)	91.5 (90.3–92.5)	90.8 (89.4–92.1)	88.5 (85.6–90.9)^††	87.1 (82.0–90.9)

Abbreviations: CI = confidence interval; HPV = human papillomavirus; MenACWY = quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella vaccine; MSA= metropolitan statistical area; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine; UTD = up-to-date.
* Adolescents (N = 18,700) in the 2018 NIS-Teen were born January 2000–February 2006.
^† MSA status was determined based on household-reported county of residence, and 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 (https://www.census.gov/programs-surveys/metro-micro.html). Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.
^§ Adolescents' health insurance status was reported by parent or guardian. "Other insurance" includes the Children's Health Insurance Program, military insurance, Indian Health Service, and any other type of health insurance not mentioned elsewhere.
^¶ Estimates with CIs >20 might be unreliable.
** Includes percentages receiving Tdap vaccine at age ≥10 years.
^†† Statistically significant difference (p<0.05) in estimated vaccination coverage by MSA or health insurance status. The referent groups were adolescents living in MSA principal city areas and adolescents with private insurance only, respectively.
^§§ Includes percentages receiving MenACWY and meningococcal-unknown type vaccine.
^¶¶ ≥2 doses of MenACWY or meningococcal-unknown type vaccine. Calculated only among adolescents aged 17 years at interview. Does not include adolescents who received 1 dose of MenACWY vaccine at age ≥16 years.
*** HPV vaccine, nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV) in females and males combined.
^††† HPV UTD includes those with ≥3 doses, and those with 2 doses when the first HPV vaccine dose was initiated at age <15 years, and there was at least 5 months minus 4 days between the first and second dose. This update to the HPV recommendation occurred in December 2016 (https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm).
^§§§ By parent/guardian report or provider records.

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National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2018

Abstract and Introduction

Introduction

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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