National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2017

1NIS-Teen is an annual survey that estimates vaccination coverage among adolescents aged 13–17 years in the 50 states, the District of Columbia (DC), selected local areas, and territories.¶ NIS-Teen is conducted among parents and guardians of eligible adolescents identified using a random-digit–dialed sample of landline and cellular telephone numbers.** Parents and guardians are interviewed by telephone about the sociodemographic characteristics of the adolescent and household. Contact information and consent to contact the teen’s vaccination providers are requested. When more than one age-eligible adolescent lives in the household, one is randomly selected for participation. 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 summarizes national vaccination coverage for 20,949 adolescents (9,845 females [47%] and 11,104 males [53%]) aged 13–17 years with adequate provider data.§§

2Data were weighted and analyzed to account for the complex sampling design of NIS-Teen. NIS-Teen methodology, including methods for weighting and synthesizing provider-reported vaccination histories, has been described previously. T-tests were used to assess vaccination coverage differences between 2017 and 2016 and between demographic subgroups (i.e., age, health insurance status, MSA status, race/ethnicity, and poverty level). Weighted linear regression by survey year was used to estimate annual percentage point changes in coverage. Trends in HPV vaccination initiation and HPV UTD status by year of birth were assessed using combined data from 2016 and 2017 NIS-Teen; p-values <0.05 were considered statistically significant.

3In 2017, coverage with ≥1 dose of HPV vaccine was 65.5% among teens, an increase of 5.1 percentage points compared with 2016; 48.6% were HPV UTD with the recommended vaccination series, an increase of 5.2 percentage points from 2016 (Table 1) (Figure). Among adolescents surveyed during 2016–2017, HPV vaccination initiation by age 13 years increased an average of 5.9 percentage points for each birth year, from 19.6% (1998 birth cohort) to 56.3% (2004 birth cohort) (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/58071). HPV UTD status by age 13 years increased an average of 3.6 percentage points for each birth year, from 7.7% (1998 birth cohort) to 29.8% (2004 birth cohort). Coverage with ≥1 and ≥2 MenACWY doses, ≥2 MMR doses, and ≥2 VAR doses also increased (Table 1). Coverage with ≥1 dose of MenB among persons aged 17 years was 14.5% (95% confidence interval [CI] = 12.3%–17.1%).

4Coverage with ≥1 dose of HPV vaccine and HPV UTD status were higher among adolescents living below the federal poverty level (73.3% and 53.7%, respectively) than among those living at or above the poverty level (62.8% and 46.7%, respectively)¶¶ (Table 2). Coverage with ≥1 dose of HPV vaccine was 10.8 percentage points lower among adolescents living in non-MSAs and 7.0 percentage points lower among those living in MSA nonprincipal cities compared with those living in MSA principal cities (Table 2). These disparities remained after controlling for poverty level.*** HPV UTD status was 10.0 percentage points lower among adolescents living in non-MSAs and 5.5 percentage points lower among those living in MSA nonprincipal cities compared with those living in MSA principal cities (Table 2). After adjusting for poverty level, differences in HPV UTD status did not persist among adolescents living in MSA nonprincipal cities, but did among adolescents living in non-MSAs compared with those living in MSA principal cities.††† ≥1- and ≥2-dose MenACWY coverage rates among adolescents living in non-MSAs were 7.4 and 12.0 percentage points lower, respectively, than those among adolescents living in MSA principal cities (Table 2). This disparity remained after controlling for poverty level.§§§ Differences in HPV vaccination coverage by race/ethnicity in 2017 were similar to patterns observed in previous years (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/58073). Coverage with ≥1 dose of HPV vaccine and HPV UTD status were 8.8 and 6.6 percentage points higher, respectively, among adolescents enrolled in Medicaid than among those with private insurance only (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/58074). HPV UTD status, ≥1-dose MenACWY, and ≥2-dose MenACWY coverage rates were 12.7, 5.0, and 22.6 percentage points lower, respectively, among uninsured adolescents than among those with private insurance (Supplementary Table 2).

5Vaccination coverage varied by jurisdiction (Table 3). Coverage with ≥1 dose of Tdap ranged from 78.9% in Alaska to 96.2% in Massachusetts; with ≥1 dose of MenACWY, from 60.7% in Wyoming to 95.3% in Georgia; and with ≥1 dose of HPV vaccine, from 46.9% in Wyoming to 91.9% in DC (Table 3) (Supplementary Figure 2, https://stacks.cdc.gov/view/cdc/58072). HPV UTD status ranged from 28.8% in Mississippi to 78.0% in DC. The largest increases in HPV UTD status from 2016 to 2017 occurred in Virginia (19.8 percentage points), DC (16.0), South Carolina (13.6), Nebraska (12.4), Dallas, Texas (11.8), Louisiana (11.1), North Carolina (10.7), Massachusetts (8.9), Vermont (8.8), and Texas (6.8) (Table 3). During 2013–2017, ≥1-dose HPV vaccination coverage increased an average of 5.1 percentage points per year nationally; the 5-year average annual increase ranged from 2.2 to 8.5 percentage points. The largest average annual increases were in Virginia (8.5 percentage points), DC (7.5), Montana (7.4), and in Arkansas, Iowa, Utah, and El Paso, Texas (7.3 percentage points each) (Supplementary Table 3, https://stacks.cdc.gov/view/cdc/58075).

6In 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.

7In 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. 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.

8HPV 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. The overall shortage of health care providers, especially pediatricians, in rural areas might partially explain the lower coverage among rural adolescents. 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. 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.

9The 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.

10HPV 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. 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.

11Vaccines to prevent human papillomavirus (HPV)–associated cancers, diphtheria, pertussis, tetanus, and meningococcal diseases are routinely recommended for persons aged 11–12 years.

12In 2017, coverage among adolescents aged 13–17 years increased for ≥1 dose of HPV vaccine and ≥1 and ≥2 doses of meningococcal vaccines and remained high for ≥1 dose of tetanus and diphtheria toxoids and acellular pertussis vaccine. HPV vaccination initiation has increased an average of 5.1 percentage points annually since 2013.

13The increase in HPV vaccination coverage indicates that further efforts to address barriers to HPV vaccination initiation and series completion likely will lead to greater protection against HPV-associated cancers.