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. 

In This Article

Discussion

In 2018, U.S. adolescent vaccination coverage with ≥1 and ≥2 doses of MenACWY, ≥1 dose of HPV vaccine and being up-to-date with HPV vaccination continued to improve. Coverage with ≥1 Tdap dose remains high but appears to have stabilized. Although HPV vaccination coverage improved, increases among all adolescents were modest compared with increases in previous years and were observed only among males. Since 2011,¶¶ coverage has increased gradually among females and more rapidly among males. However, only approximately half of adolescents have been fully vaccinated for HPV.

HPV vaccination coverage was higher among adolescents whose parent reported receiving a provider recommendation. Thus, the provider recommendation continues to be a strong predictor of HPV vaccination.[3,4] However, even when a provider recommendation was given, only 75% accepted the vaccine, suggesting that there are other reasons adolescents are not being vaccinated. Equipping providers with the tools they need to give strong recommendations that emphasize the importance of HPV vaccination in preventing cancer and effectively address parental concerns is a priority, especially in states where provider recommendations were less commonly reported. Resources on the importance of HPV vaccination and videos demonstrating how to give a recommendation are available to facilitate discussion between providers, teens, and their parents (https://www.cdc.gov/vaccines/vpd/hpv/hcp/resources.html).

Coverage disparities persisted for some vaccines by MSA status. The disparity in HPV vaccination coverage by MSA status is not well understood; however, the lower prevalence of provider recommendations in non-MSA areas might be a factor. In one study, parents and guardians in the rural South indicated that they did not have enough information on the vaccine or its purpose.[5] Efforts to ensure that rural health care providers have the resources and training necessary to educate parents and guardians about the benefits of HPV vaccination as a cancer prevention tool might increase the number of adolescents protected against diseases caused by HPV.

Vaccination coverage was significantly lower among uninsured adolescents than among those with private insurance. Adolescents without health insurance are eligible to receive vaccines through the Vaccines for Children (VFC) program.*** Lack of parental awareness of[6] and misconceptions about the program, including that it is only for infants and younger children, might serve as barriers.[7] Increasing parental awareness and knowledge of the VFC program should improve vaccination coverage among uninsured adolescents. Providers can assist by ensuring that their health care practice routinely screen patients for eligibility and counsel families about the VFC program.

The findings in this report are subject to at least seven limitations. First, the overall Council of American Survey Research Organizations response rate was low, and fewer than half of adolescents with completed interviews had adequate provider data. Second, bias in estimates might remain even after adjustment for household and provider nonresponse and landline-only and phoneless households.††† Third, changes in estimates of vaccination coverage from 2017 to 2018 should be interpreted with caution, given the transition from dual landline- and cellular- to single-cellular telephone-sampling frame in 2018. Fourth, estimates stratified by jurisdiction might be unreliable because of small sample sizes. Fifth, multiple statistical tests were conducted, and a small number might be significant because of chance alone. Sixth, coverage with ≥2 doses of MenACWY and ≥1 dose of MenB might be underestimated because MenB and second MenACWY dose may be administered at age >17 years,[1] and NIS-Teen includes adolescents aged 13–17 years. Finally, the "provider recommendation" variable is based on parental report and thus subject to recall bias.

It is encouraging that HPV vaccination coverage among boys continues to increase; however, the lack of an increase among girls is concerning. In the United States, an estimated 34,800 cases of cancer caused by HPV occur each year; 32,100 (92%), including 59% among women, would be preventable by the 9-valent HPV vaccine.[8] Although, HPV vaccination has resulted in large declines in the prevalence of vaccine type HPV infections among adolescent girls and young adults,[9] as well as decreases in cervical precancers,[10] continuing to improve HPV vaccination coverage for all adolescents, male and female, will ensure they are protected from HPV infection and diseases caused by HPV, including cancers.

¶¶ ACIP recommended a 3-dose series of HPV vaccine for girls aged 11 to 12 years in 2006 (https://www.cdc.gov/Mmwr/Preview/Mmwrhtml/rr5602a1.htm) and for boys in 2011 (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm). In 2016, the recommendation was revised to a 2-dose series for immunocompetent adolescents beginning the series before their 15th birthday with appropriate spacing between doses. All other persons are recommended to complete a 3 dose vaccine series (https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm).
*** Children and adolescents aged ≤18 years who are Medicaid-eligible, uninsured, or American Indian/Alaska Native (as defined by the Indian Health Care Improvement Act) are eligible to receive vaccines from providers through the VFC program. Children and adolescents categorized as "underinsured" (because their health plans do not include coverage for recommended vaccinations) are eligible to receive VFC vaccines if they are served by a rural health clinic or federally qualified health center or under an approved deputization agreement. (https://www.cdc.gov/vaccines/programs/vfc/providers/eligibility.html)
††† In a sensitivity analysis of 2013 estimates using comparisons to vaccination data collected from a sample of National Health Interview Survey (NHIS), respondents indicated that estimated coverage with ≥1 Tdap dose, ≥1 MenACWY dose, and ≥1 HPV dose (females) were within two percentage points of true estimates (https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-TEEN-PUF17-DUG.pdf). These differences were within the margin of plausible error of the model. The model accounted for three types of error: incomplete sample frame (e.g., exclusion of teens in households with no type of telephone service); nonresponse bias; and incomplete ascertainment of vaccination status by NIS-Teen provider record check.

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