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


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

In This Article


In 2019, coverage with HPV vaccine and with MenACWY improved compared with coverage in 2018. Improvements in ≥1 dose HPV and HPV UTD vaccination coverage were observed among females and males. In addition, more teens began HPV vaccination on time (by age 13 years) in 2019, suggesting that more parents are making the decision to protect their teens against HPV-associated cancers. Efforts from federal, state, and other stakeholders to prioritize HPV vaccination among adolescents, and reducing the number of recommended HPV vaccine doses from a 3-dose to a 2-dose series,[2] likely contributed to these improvements. Coverage with ≥1 dose of MenACWY increased to 88.9%; coverage with ≥2 doses remained low at 53.7%, indicating that continued efforts are needed to improve receipt of the booster dose.

Despite progress in adolescent HPV vaccination and MenACWY coverage, disparities remain; all adolescents are not equally protected against vaccine-preventable diseases. As in previous years, compared with adolescents living in MSA principal cities, HPV UTD status and coverage with ≥1 dose each of HPV vaccine and MenACWY continue to be lower among adolescents in non-MSA areas.[3] However, these geographic disparities were present only for adolescents at or above the poverty level in 2019. This finding is consistent with another study that found socioeconomic status to be a moderating factor in the association between HPV vaccination and MSA.[4] The lack of an MSA disparity among adolescents below the poverty level might reflect the access that low-income adolescents have to the VFC program****; previous studies have reported higher HPV vaccination coverage rates among adolescents living below the poverty level.[5,6] Reasons for the MSA disparity among higher socioeconomic status adolescents are less clear but might be an indicator of lower vaccine confidence. More work is needed to understand the relationship between socioeconomic status and geographic disparities and the barriers that might be contributing to such differences.

The findings in this report are subject to at least two limitations. First, the CASRO response rate to NIS-Teen was 19.7%, and only 44.0% of households with completed interviews had adequate provider data. A portion of the questionnaires sent to vaccination provider(s) to request the adolescent's vaccination history were mailed in early 2020. A lower response rate was observed for those requests, likely because of the effect of the COVID-19 pandemic on health care provider operations.†††† Second, even with adjustments for household and provider nonresponse, landline-only households, and phoneless households, a bias in the estimates might remain.§§§§

The COVID-19 pandemic has the potential to offset historically high vaccination coverage with Tdap and MenACWY and to reverse gains made in HPV vaccination coverage. Orders for adolescent vaccines have decreased among VFC providers during the pandemic. A recent analysis using VFC provider ordering data showed a decline in vaccine orders for several VFC-funded noninfluenza childhood vaccines since mid-March when COVID-19 was declared a national emergency.[7] CDC, along with other national health organizations, continues to stress the importance of well-child visits and vaccinations as essential services.[8] The majority of practices appear to be open and resuming vaccination activities for their pediatric patients.[9,10] Providers can take several steps to ensure that adolescents are up to date with recommended vaccines. These include 1) promoting well-child and vaccination visits; 2) following guidance on safely providing vaccinations during the COVID-19 pandemic¶¶¶¶; 3) leveraging reminder and recall systems to remind parents of their teen's upcoming appointment, and recalling those who missed appointments and vaccinations; and 4) educating eligible patients and parents, especially those who might have lost employer-funded insurance benefits, about the availability of publicly funded vaccines through the VFC program. In addition, state, local, and territorial immunization programs can consider using available immunization information system data***** to identify local areas and sociodemographic groups at risk for undervaccination related to the pandemic, and to help prioritize resources aimed at improving adolescent vaccination coverage.

****Children 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 Vaccines for Children (VFC) program. Children 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.
††††The Provider Record Check (PRC) phase of the NIS, which is conducted in Chicago, was disrupted on March 21, 2020, by a COVID-19–related stay-at-home order issued by the State of Illinois. This disruption meant that some 2019 NIS-Teen data received from responding providers could not be processed and resulted in a lower rate of adolescents with adequate provider data in Quarter 4 among those with consent to contact vaccination providers. NORC at the University of Chicago (, the NIS contractor, assessed the effect of the early close of the PRC operation. They found the adequate provider data rate was lower in Quarter 4 than in previous quarters, but that did not affect the demographics of children with adequate provider data or vaccination coverage estimates for MenACWY or HPV vaccines. Logistic regression models indicate that, after controlling for demographic covariates, the odds of being vaccinated with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) were lower in Quarter 4 compared with previous quarters, but the effect on the vaccination coverage rate estimate itself was minor.
§§§§An assessment of validity of the 2018 NIS-Teen estimates has been reported (, pages 62–69). NIS-Teen vaccination coverage estimates tended to be slightly low compared with true values derived after adjusting for noncoverage, nonresponse, and vaccination under-acertainment, reaching up to 5.7 percentage points too low for Tdap. This was primarily attributed to under-ascertainment of vaccinations by the NIS provider record check. The validity of estimates did not change from 2017 to 2018.