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

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of persons aged 11–12 years with human papillomavirus (HPV) vaccine, quadrivalent meningococcal conjugate vaccine (MenACWY), and tetanus and reduced diphtheria toxoids and acellular pertussis vaccine (Tdap). A booster dose of MenACWY is recommended at age 16 years (1), and catch-up vaccination is recommended for hepatitis B vaccine (HepB), measles, mumps, and rubella vaccine (MMR), and varicella vaccine (VAR) for adolescents whose childhood vaccinations are not up to date (UTD) (1). ACIP also recommends that clinicians may administer a serogroup B meningococcal vaccine (MenB) series to adolescents and young adults aged 16–23 years, with a preferred age of 16–18 years (2). To estimate U.S. adolescent vaccination coverage, CDC analyzed data from the 2017 National Immunization Survey–Teen (NIS-Teen) for 20,949 adolescents aged 13–17 years.* During 2016–2017, coverage increased for ≥1 dose of HPV vaccine (from 60.4% to 65.5%), ≥1 dose of MenACWY (82.2% to 85.1%), and ≥2 doses of MenACWY (39.1% to 44.3%). Coverage with Tdap remained stable at 88.7%. In 2017, 48.6% of adolescents were UTD with the HPV vaccine series (HPV UTD) compared with 43.4% in 2016.† On-time vaccination (receipt of ≥2 or ≥3 doses of HPV vaccine by age 13 years) also increased. As in 2016, ≥1-dose HPV vaccination coverage was lower among adolescents living in nonmetropolitan statistical areas (MSAs) (59.3%) than among those living in MSA principal cities (70.1%).§ Although HPV vaccination initiation remains lower than coverage with MenACWY and Tdap, HPV vaccination coverage has increased an average of 5.1 percentage points annually since 2013, indicating that continued efforts to target unvaccinated teens and eliminate missed vaccination opportunities might lead to HPV vaccination coverage levels comparable to those of other routinely recommended adolescent vaccines.

in nonmetropolitan statistical areas (MSAs) (59.3%) than among those living in MSA principal cities (70.1%).§ Although HPV vaccination initiation remains lower than coverage with MenACWY and Tdap, HPV vaccination coverage has increased an average of 5.1 percentage points annually since 2013, indicating that continued efforts to target unvaccinated teens and eliminate missed vaccination opportunities might lead to HPV vaccination coverage levels comparable to those of other routinely recommended adolescent vaccines.
NIS-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 randomdigit-dialed sample of landline and cellular telephone § MSA status was determined based on household reported city and county of residence, and status 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/geo/reference/gtc/gtc_cbsa.html).Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.¶ The following 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.Three local areas were oversampled (Dallas County, Texas, El Paso County, Texas, and Travis County, Texas).Three territories were sampled separately in 2017 (Guam, Puerto Rico, and the U.S. Virgin Islands).Because of the severity of 2017's hurricane season, survey operations in Puerto Rico and the U.S. Virgin Islands were suspended resulting in insufficient data for estimation of vaccination coverage.
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 providerreported vaccination histories.This report summarizes national vaccination coverage for 20,949 adolescents (9,845 females ** All identified cellular-telephone households were eligible for interview. Sampling weights were adjusted for dual-frame (landline and cellular telephone), nonresponse, noncoverage, and overlapping samples of mixed telephone users.A description of NIS-Teen dual-frame survey methodology and its effect on reported vaccination estimates is available at https://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/dual-frame-sampling.html.Starting in 2018, the landline telephone sample was dropped.† † For the telephone samples for the states and local areas, the overall Council of American Survey Research Organizations (CASRO) response rate was 25.7% (51.5% for the landline sample and 23.5% for the cellular-telephone sample).For adolescents with completed interviews, 48.1% had adequate provider data (53.6%landline sample, 47.1% cell sample).Among completed interviews with adequate provider data, 17% (3,572) were from the landline sample, and 83% (17,377) were from the cellular telephone sample.For Guam, the overall CASRO response rate was 31.3%.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).
[47%] and 11,104 males [53%]) aged 13-17 years with adequate provider data.§ § Data 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 (3).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.

Vaccination Coverage by Selected Characteristics
Coverage 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 § § Adolescents from Guam (n = 382).¶ ¶ Adolescents were classified as 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.† † † 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 at least 5 months minus 4 days elapsed between the first and second dose.This update to the HPV recommendation occurred in December of 2016.§ § § By parent/guardian report or provider records.

Discussion
In 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.Because HPV vaccination was not recommended for males until 2011, coverage for all adolescents was not measured before that year; 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 at least 5 months minus 4 days elapsed between the first and second dose.† ACIP revised the recommended HPV vaccination schedule in late 2016.The recommendation changed from a 3-dose to 2-dose series with appropriate spacing between receipt of the first and second dose for immunocompetent adolescents initiating the series before the 15th birthday.Three doses are still recommended for adolescents initiating the series between the ages of 15 and 26 years.Because of the change in recommendation, the graph includes estimates for ≥3 doses HPV from 2011 to 2015 and the HPV UTD estimate for 2016 and 2017.Because HPV vaccination was recommended for boys in 2011, coverage for all adolescents was not measured before that year.§ NIS-Teen implemented a revised adequate provider data definition (APD) in 2014, and retrospectively applied the revised APD definition to 2013 data.Estimates using different APD definitions may not be directly comparable.
In 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 (5).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 (6).
HPV 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 (7,8).The overall shortage of health care providers, especially pediatricians, in rural areas might partially explain the lower coverage among rural adolescents (8,9).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 (7).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.
The 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 phoneonly households over time.Nonresponse bias might change, ¶ ¶ ¶ In a sensitivity analysis of 2013 NIS-Teen data, including adjustments for incomplete sample frame, nonresponse bias, and incomplete ascertainment of vaccination status, estimates of Tdap, ≥1 dose MenACWY, and ≥1 dose HPV vaccine coverage, were estimated to be lower than actual values by 1-3 percentage points https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-TEEN-PUF16-DUG.pdf.† Adolescents were classified as below 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.Additional information available at https://www.census.gov/data/tables/time-series/demo/income-poverty/historicalpoverty-thresholds.html.Poverty status was unknown for 779 adolescents.§ MSA status was determined based on household-reported county and city 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/geo/reference/gtc/gtc_cbsa.html).Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.¶ Estimates with 95% CIs >20 might be unreliable.** Includes percentages receiving Tdap vaccine at age ≥10 years.
† † Includes percentages receiving MenACWY and meningococcal vaccine of unknown type.§ § Statistically significant difference (p<0.05) in estimated vaccination coverage by poverty level or metropolitan statistical area; the referent groups were adolescents living at or above poverty level and MSA principal city respectively.¶ ¶ ≥2 doses of MenACWY or meningococcal vaccine of unknown type vaccine.Calculated only among adolescents aged 17 years at interview.Does not include adolescents who received one 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 at least 5 months minus 4 days elapsed between the first and second dose.This update to the HPV recommendation occurred in December of 2016.§ § § By parent/guardian report or provider records.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 (1).
HPV 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 (10).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.
Abbreviations: CI = confidence interval; HPV = human papillomavirus; MenACWY = quadrivalent meningococcal conjugate 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 = 20,949) in the 2017 NIS-Teen were born January 1999 through February 2005.†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 vaccine of unknown type.† † Statistically significant difference (p<0.05)compared with 2016 NIS-Teen estimates.§ § ≥2 doses of MenACWY or meningococcal vaccine of unknown type.Calculated only among adolescents who were aged 17 years at interview.Does not include adolescents who received one dose of MenACWY vaccine at age ≥16 years.¶ ¶ HPV vaccine, nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV).For ≥1 dose measures, percentages are reported among females and males combined (N = 20,949) and for females only (N = 9,845) and males only (N = 11,104).*** Statistically significant difference (p<0.05) in estimated vaccination coverage at age 13 years compared with 2016 NIS-Teen estimates.†† † 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 at least 5 months minus 4 days elapsed between the first and second dose.This update to the HPV recommendation occurred in December of 2016.§ § § By parent/guardian report or provider records.

FIGURE.
FIGURE.Estimated coverage with selected vaccines and doses* among adolescents aged 13-17 years, by survey year and ACIP recommendations † -National Immunization Survey-Teen, United States, 2006-2017 §

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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 = 20,949) in the 2017 NIS-Teen were born January 1999 through February 2005.† Adolescents were classified as below 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.Additional information available at https://www.census.gov/data/tables/time-series/demo/income-poverty/historicalpoverty-thresholds.html.Poverty status was unknown for 779 adolescents.§ MSA status was determined based on household-reported county and city 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/geo/reference/gtc/gtc_cbsa.html).Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.¶ Estimates with 95% CIs >20 might be unreliable.** Includes percentages receiving Tdap vaccine at age ≥10 years.†† Includes percentages receiving MenACWY and meningococcal vaccine of unknown type.§ § Statistically significant difference (p<0.05) in estimated vaccination coverage by poverty level or metropolitan statistical area; the referent groups were adolescents living at or above poverty level and MSA principal city respectively.¶ ¶ ≥2 doses of MenACWY or meningococcal vaccine of unknown type vaccine.Calculated only among adolescents aged 17 years at interview.Does not include adolescents who received one 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 at least 5 months minus 4 days elapsed between the first and second dose.This update to the HPV recommendation occurred in December of 2016.§ § § By parent/guardian report or provider records.

TABLE 3 .
(Continued) Estimated vaccination coverage with selected vaccines and doses* among adolescents aged 13-17 years, † by HHS region, state, selected local area, or territory -National Immunization Survey-Teen (NIS-Teen), United States,