National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2019

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

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(33):1109-1116.

Abstract and Introduction

Introduction

Three vaccines are recommended by the Advisory Committee on Immunization Practices (ACIP) for routine vaccination of adolescents aged 11–12 years to protect against 1) pertussis; 2) meningococcal disease caused by types A, C, W, and Y; and 3) human papillomavirus (HPV)-associated cancers.^[1] At age 16 years, a booster dose of quadrivalent meningococcal conjugate vaccine (MenACWY) is recommended. Persons aged 16–23 years can receive serogroup B meningococcal vaccine (MenB), if determined to be appropriate through shared clinical decision-making. CDC analyzed data from the 2019 National Immunization Survey-Teen (NIS-Teen) to estimate vaccination coverage among adolescents aged 13–17 years in the United States.* Coverage with ≥1 dose of HPV vaccine increased from 68.1% in 2018 to 71.5% in 2019, and the percentage of adolescents who were up to date^† with the HPV vaccination series (HPV UTD) increased from 51.1% in 2018 to 54.2% in 2019. Both HPV vaccination coverage measures improved among females and males. An increase in adolescent coverage with ≥1 dose of MenACWY (from 86.6% in 2018 to 88.9% in 2019) also was observed. Among adolescents aged 17 years, 53.7% received the booster dose of MenACWY in 2019, not statistically different from 50.8% in 2018; 21.8% received ≥1 dose of MenB, a 4.6 percentage point increase from 17.2% in 2018. Among adolescents living at or above the poverty level,^§ those living outside a metropolitan statistical area (MSA)^¶ had lower coverage with ≥1 dose of MenACWY and with ≥1 HPV vaccine dose, and a lower percentage were HPV UTD, compared with those living in MSA principal cities. In early 2020, the coronavirus disease 2019 (COVID-19) pandemic changed the way health care providers operate and provide routine and essential services. An examination of Vaccines for Children (VFC) provider ordering data showed that vaccine orders for HPV vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap); and MenACWY decreased in mid-March when COVID-19 was declared a national emergency (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/91795). Ensuring that routine immunization services for adolescents are maintained or reinitiated is essential to continuing progress in protecting persons and communities from vaccine-preventable diseases and outbreaks.

NIS-Teen is a random-digit-dial telephone survey** conducted annually to monitor vaccination coverage among adolescents aged 13–17 years in the 50 states, the District of Columbia, selected local areas, and selected U.S. territories.^†† Sociodemographic information is collected during the telephone interview with a parent or guardian, and a request is made for consent to contact the adolescent's vaccination provider(s). If consent is obtained, a questionnaire is mailed to the vaccination provider(s) to request the adolescent's vaccination history. Vaccination coverage estimates are determined from these provider-reported immunization records. This report provides vaccination coverage estimates on 18,788 adolescents aged 13–17 years.^§§ The overall Council of American Survey Research Organizations (CASRO)^¶¶ response rate was 19.7%, and 44.0% of adolescents for whom household interviews were completed had adequate provider data.

Data were weighted and analyzed to account for the complex sampling design.*** T-tests were used to assess vaccination coverage differences between sociodemographic subgroups. P-values <0.05 were considered statistically significant. All analyses were conducted using SAS-callable SUDAAN (version 11; RTI International).

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Abstract and Introduction
National Vaccination Coverage
Vaccination Coverage By Selected Characteristics
Trends in HPV Vaccination by Birth Cohort
Discussion
References
Sidebar

*Eligible participants were born during January 2001–February 2007. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) represents coverage with ≥1 Tdap dose at age ≥10 years. Meningococcal conjugate vaccine (MenACWY) represents coverage with the quadrivalent meningococcal conjugate vaccine or meningococcal-unknown type vaccine. Human papillomavirus (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 two or three recommended HPV vaccine doses. Estimates for hepatitis A, hepatitis B, and measles, mumps, and rubella vaccines represent coverage based on the catch-up schedule for adolescents who are 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 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 each 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.
^§Adolescents were classified as being below the federal poverty level if their total family income was less than the federal poverty level specified for the applicable family size and number of children aged <18 years. All others were classified as at or above the poverty level (https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html). Poverty status was unknown for 657 adolescents.
^¶Metropolitan statistical area (MSA) status was determined from household reported city and county of residence and was grouped into three categories: MSA principal city, MSA nonprincipal city, and non-MSA. MSA and MSA 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 and completely rural areas.
**All identified cellular-telephone households were eligible for interview. Sampling weights were adjusted for single frame (cellular telephone), nonresponse, noncoverage, and overlapping samples of mixed telephone users. 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.
^††Local areas that received federal immunization funds under Section 317 of the Public Health Service Act were sampled separately. Those included Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas. Two local areas were oversampled in 2019: Dallas County, Texas, and El Paso County, Texas. Three territories were sampled separately in 2019: Guam, Puerto Rico, and the U.S. Virgin Islands.
^§§Adolescents from Guam (n = 278), Puerto Rico (n = 216), and U.S. Virgin Island (n = 218) were excluded from the national estimates.
^¶¶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).
***The NIS-Teen methodology for weighting and synthesizing provider-reported vaccination histories has been previously described. https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-Teen-PUF18-DUG.pdf.

Table 1. Estimated vaccination coverage with selected vaccines and doses among adolescents aged 13–17* years, by age at interview — National Immunization Survey–Teen (NIS-Teen), United States, 2019
Vaccine	Age at interview, yrs % (95% CI)^†					Total % (95% CI)^†
Vaccine	13 (n = 3,927)	14 (n = 4,007)	15 (n = 3,753)	16 (n = 3,753)	17 (n = 3,348)	2019 (n = 18,788)	2018 (n = 18,700)
Tdap^§ ≥1 dose	89.0 (87.2–90.6)	91.8 (89.6–93.5)^¶	91.4 (89.6–92.9)	89.5 (87.4–91.3)	88.9 (85.3–91.7)	90.2 (89.2–91.1)	88.9 (88.0–89.7)
MenACWY**
≥1 dose	87.7 (86.0–89.3)	91.2 (89.6–92.5)^¶	88.3 (86.2–90.1)	88.3 (85.8–90.4)	88.9 (85.9–91.4)	88.9 (88.0–89.8)^††	86.6 (85.6–87.5)
≥2 doses^§§	NA	NA	NA	NA	53.7 (49.9–57.4)	53.7 (49.9–57.4)	50.8 (47.7–53.8)
HPV^¶¶ vaccine
All adolescents
≥1 dose	66.9 (64.1–69.6)	73.6 (70.8–76.3)^¶	72.1 (69.1–75.0)^¶	71.2 (68.1–74.0)^¶	73.1 (69.7–76.3)^¶	71.5 (70.1–72.8)^††	68.1 (66.8–69.3)
HPV UTD***	45.3 (42.1–48.5)	52.2 (48.6–55.8)^¶	58.6 (55.3–61.8)^¶	57.6 (54.4–60.8)^¶	57.1 (53.2–60.8)^¶	54.2 (52.7–55.8)^††	51.1 (49.8–52.5)
Females
≥1 dose	68.4 (64.0–72.5)	75.1 (71.4–78.5)^¶	75.6 (71.6–79.2)^¶	71.9 (67.1–76.3)	74.9 (70.0–79.2)^¶	73.2 (71.3–75.0)^††	69.9 (68.1–71.6)
HPV UTD	48.9 (43.9–53.9)	53.0 (48.0–57.9)	61.6 (57.0–66.0)^¶	61.5 (56.8–66.0)^¶	59.2 (53.6–64.5)^¶	56.8 (54.6–59.0)^††	53.7 (51.8–55.6)
Males
≥1 dose	65.4 (61.8–68.8)	72.2 (67.8–76.1)^¶	68.9 (64.3–73.1)	70.4 (66.4–74.1)	71.6 (66.6–76.1)^¶	69.8 (67.9–71.7)^††	66.3 (64.6–68.0)
HPV UTD	41.5 (37.9–45.3)	51.5 (46.2–56.7)^¶	55.7 (51.1–60.2)^¶	53.9 (49.5–58.2)^¶	55.2 (49.9–60.4)^¶	51.8 (49.7–53.9)^††	48.7 (46.8–50.6)
MenB ≥1 dose^†††	NA	NA	NA	NA	21.8 (18.9–24.9)	21.8 (18.9–24.9)^††	17.2 (14.9–19.9)
MMR ≥2 doses	93.0 (91.1–94.4)	91.2 (88.1–93.5)	93.3 (91.7–94.6)	91.2 (89.0–92.9)	90.7 (87.5–93.2)	91.9 (90.8–92.8)	91.9 (91.2–92.6)
Hepatitis A vaccine ≥2 doses^§§§	84.1 (81.6–86.2)	79.8 (76.7–82.6)^¶	78.1 (75.3–80.6)^¶	71.8 (68.9–74.5)^¶	71.9 (68.1–75.4)^¶	77.1 (75.8–78.4)^††	73.6 (72.4–74.7)
Hepatitis B vaccine ≥3 doses	92.1 (90.1–93.7)	91.6 (88.6–93.8)	92.8 (91.1–94.2)	90.7 (88.5–92.5)	90.8 (87.4–93.4)	91.6 (90.6–92.6)	92.1 (91.3–92.8)
Varicella
History of varicella^¶¶¶	6.8 (5.4–8.5)	8.4 (7.0–10.0)	9.6 (8.0–11.4)^¶	10.4 (8.7–12.3)^¶	10.4 (8.8–12.4)^¶	9.1 (8.4–9.9)^††	11.9 (11.0–12.7)
No history of varicella disease
≥1 dose vaccine	96.0 (94.9–96.8)	94.7 (92.1–96.5)	95.8 (94.6–96.7)	94.4 (92.3–95.9)	95.0 (92.2–96.9)	95.2 (94.3–95.9)	94.9 (94.3–95.4)
≥2 doses vaccine	91.6 (89.6–93.2)	91.0 (87.7–93.5)	92.5 (90.9–93.8)	90.1 (87.7–92.0)	87.8 (84.1–90.7)	90.6 (89.5–91.7)	89.6 (88.7–90.4)
Varicella disease or received ≥2 varicella vaccine doses	92.2 (90.3–93.7)	91.8 (88.7–94.0)	93.2 (91.8–94.4)	91.1 (88.9–92.9)	89.1 (85.7–91.7)	91.5 (90.4–92.4)	90.8 (90.0–91.6)

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 = 18,788) in the 2019 NIS-Teen were born during January 2001–February 2007.
^†Estimates with 95% CIs >20 might not be reliable.
^§Includes percentages receiving Tdap 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 2018 NIS-Teen estimates.
^§§≥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 at age ≥16 years.
^¶¶HPV vaccine, nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV). For ≥1 dose and HPV UTD measures, percentages are reported among females and males combined (N = 18,788) and for females only (N = 8,916) and males only (N = 9,872).
***HPV UTD includes those with ≥3 doses, and those with 2 doses when the first HPV vaccine dose was initiated before 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 of 2016.
^†††≥1 dose of MenB, administered based on individual clinical decision; calculated only among adolescents aged 17 years at interview.
^§§§In July 2020, ACIP revised recommendations for hepatitis A vaccination to include catch-up vaccination for children and adolescents aged 2–18 years who have not previously received hepatitis A vaccine at any age (https://dx.doi.org/10.15585/mmwr.rr6905a1).
^¶¶¶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 (MSA) ^† and by poverty level — National Immunization Survey–Teen (NIS-Teen), United States, 2019
Vaccine	MSA % (95% CI)^§			Below poverty level % (95% CI)^§			At or above poverty level % (95% CI)^§
Vaccine	Non-MSA (n = 3,689)	MSA nonprincipal city (n = 7,745)	MSA principal city (n = 7,354)	Non-MSA (n = 607)	MSA nonprincipal city (n = 820)	MSA principal city (n = 1,376)	Non-MSA (n = 2,962)	MSA nonprincipal city (n = 6,676)	MSA principal city (n = 5,687)
Tdap^¶ ≥1 dose	88.7 (86.7–90.5)	90.5 (89.0–91.8)	90.2 (88.5–91.7)	92.2 (88.7–94.6)	87.6 (80.3–92.4)	88.9 (86.0–91.3)	88.0 (85.6–90.1)	90.9 (89.5–92.1)	90.6 (88.4–92.4)
MenACWY**
≥1 dose	83.5 (80.9–85.8)^††	90.3 (89.1–91.4)	88.6 (86.8–90.2)	90.4 (87.0–93.0)	92.4 (88.5–95.1)	88.3 (84.6–91.1)	82.2 (79.0–85.0)^††	89.7 (88.4–90.9)	88.8 (86.5–90.7)
≥2 doses^§§	46.6 (39.2–54.2)	55.5 (49.9–61.0)	53.3 (46.9–59.5)	36.5 (23.5–51.8)^††	51.5 (33.4–69.3)	59.5 (47.9–70.2)	48.8 (40.1–57.5)	57.1 (51.6–62.4)	50.8 (43.3–58.3)
HPV^¶¶ vaccine
All adolescents
≥1 dose	64.2 (61.2–67.2)^††	71.2 (69.2–73.1)	73.8 (71.5–75.9)	72.6 (66.8–77.7)	75.2 (67.9–81.3)	76.5 (71.4–81.0)	62.6 (59.0–66.1)^††	70.3 (68.3–72.2)	72.4 (69.8–74.9)
HPV UTD***	47.3 (44.2–50.4)^††	53.4 (51.2–55.7)^††	57.1 (54.6–59.5)	54.6 (48.4–60.7)	58.8 (51.2–66.0)	58.8 (53.5–63.9)	45.4 (41.8–49.1)^††	52.7 (50.3–55.0)^††	56.5 (53.6–59.4)
Females
≥1 dose	66.3 (61.7–70.7)^††	72.3 (69.5–75.0)	75.9 (72.9–78.7)	76.2 (67.3–83.3)	73.0 (61.2–82.2)	78.4 (72.4–83.4)	64.0 (58.5–69.2)^††	72.2 (69.6–74.7)	75.0 (71.3–78.4)
HPV UTD	49.0 (44.6–53.5)^††	56.1 (53.0–59.2)	59.4 (55.7–63.1)	60.1 (51.0–68.4)	58.3 (47.3–68.4)	60.2 (53.3–66.7)	45.6 (40.6–50.7)^††	55.3 (52.1–58.4)	58.7 (54.2–63.1)
Males
≥1 dose	62.4 (58.2–66.4)^††	70.2 (67.4–72.9)	71.4 (68.2–74.5)	69.4 (61.5–76.4)	77.5 (68.6–84.4)	74.8 (66.5–81.6)	61.3 (56.4–66.1)^††	68.6 (65.6–71.5)	69.6 (65.9–73.1)
HPV UTD	45.7 (41.3–50.1)^††	51.0 (47.7–54.3)	54.6 (51.4–57.8)	49.8 (41.4–58.3)	59.4 (48.7–69.3)	57.5 (49.6–65.1)	45.2 (40.0–50.5)^††	50.5 (47.0–53.9)	54.1 (50.5–57.7)
MMR ≥2 doses	91.7 (90.0–93.1)	92.3 (91.0–93.3)	91.4 (89.3–93.2)	91.6 (87.6–94.4)	93.7 (90.3–95.9)	93.6 (91.6–95.1)	91.9 (90.0–93.5)	92.2 (90.8–93.4)	91.0 (88.0–93.2)
Hepatitis A vaccine ≥2 doses^†††	67.4 (64.5–70.2)^††	77.1 (75.1–78.9)	79.8 (77.6–81.9)	65.5 (59.0–71.4)^††	82.2 (77.0–86.5)	81.1 (77.1–84.5)	68.1 (64.8–71.3)^††	76.9 (74.9–78.9)	79.6 (76.9–82.1)
Hepatitis B vaccine ≥3 doses	92.5 (90.9–93.9)	92.0 (90.6–93.2)	90.9 (88.9–92.6)	92.8 (89.4–95.1)	92.6 (89.2–95.0)	91.0 (88.1–93.2)	92.7 (90.8–94.2)	92.9 (91.6–93.9)	91.4 (88.7–93.5)
Varicella
History of varicella^§§§	12.4 (10.3–15.0)^††	8.3 (7.3– 9.3)	9.3 (8.1–10.6)	9.8 (7.1–13.4)	8.2 (5.9–11.2)^††	12.3 (9.5–15.6)	13.0 (10.3–16.3)^††	7.8 (6.8–8.9)	8.2 (7.0–9.6)
No history of varicella disease
≥1 dose vaccine	95.0 (93.4–96.2)	95.6 (94.6–96.4)	94.7 (92.9–96.1)	95.7 (92.4–97.6)	95.0 (91.9–97.0)	95.2 (93.2–96.6)	95.2 (93.4–96.5)	95.6 (94.5–96.4)	94.8 (92.3–96.6)
≥2 doses vaccine	90.9 (89.1–92.4)	91.4 (90.2–92.6)	89.6 (87.1–91.6)	90.7 (86.2–93.9)	93.0 (89.6–95.4)	92.9 (90.7–94.6)	91.3 (89.2–93.0)	91.0 (89.6–92.3)	89.1 (85.8–91.6)
Varicella disease or received ≥2 varicella vaccine doses	92.0 (90.4–93.4)	92.1 (91.0–93.2)	90.5 (88.3–92.4)	91.6 (87.6–94.5)	93.6 (90.4–95.7)	93.7 (91.8–95.2)	92.4 (90.6–93.9)	91.7 (90.4–92.9)	90.0 (86.9–92.3)

Abbreviations: CI = confidence interval; HPV = human papillomavirus; MenACWY = quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine; UTD = up-to-date.
*Adolescents (N = 18,788) in the 2019 NIS-Teen were born January 2001 through February 2007.
^†MSA status was determined by 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/about.html). Non-MSA areas include urban populations not located within an MSA and completely rural areas.
^§Estimates with 95% CIs >20 might not be reliable.
^¶Includes percentages receiving Tdap at age ≥10 years.
**Includes percentages receiving MenACWY and meningococcal-unknown type vaccine.
^††Statistically significant difference (p<0.05) in estimated vaccination coverage by MSA; referent group was adolescents living in MSA principal city areas.
^§§≥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 at age ≥16 years.
^¶¶HPV vaccine, nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV).
***HPV UTD includes those who've received ≥3 doses and those with 2 doses when the first HPV vaccine dose was initiated before 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 of 2016.
^†††In July 2020, ACIP revised recommendations for Hepatitis A vaccination to include catch-up vaccination for children and adolescents aged 2–18 years who have not previously received Hepatitis A vaccine at any age (https://dx.doi.org/10.15585/mmwr.rr6905a1).
^§§§By parent/guardian report or provider records.