National, State, and Local Area Vaccination Coverage among Adolescents Aged 13--17 Years --- United States, 2009

The Advisory Committee for Immunization Practices (ACIP) recommends that adolescents routinely receive the following vaccines: meningococcal conjugate (MenACWY, 1 dose); tetanus, diphtheria, acellular pertussis (Tdap, 1 dose); and (for females) human papillomavirus (HPV, 3 doses) (1). Adolescents also should receive the following recommended vaccinations they missed during childhood: measles, mumps, rubella (MMR, 2 doses); hepatitis B (HepB, 3 doses); and varicella (VAR, 2 doses) (1). Since 2006, CDC has conducted the National Immunization Survey--Teen (NIS-Teen) to estimate vaccination coverage among adolescents aged 13--17 years. This report summarizes results from 2009 NIS-Teen and updates data from 2008 NIS-Teen (2). Comparing 2009 with 2008, vaccination coverage among adolescents for the three routinely administered adolescent vaccines increased for Tdap (from 40.8% to 55.6%), MenACWY (from 41.8% to 53.6%), ≥1 dose of HPV (from 37.2% to 44.3%), and ≥3 doses of HPV (from 17.9% to 26.7%). Vaccination coverage varied widely among states; four states (Connecticut, Massachusetts, New Hampshire, and Rhode Island) had coverage of >60% for all three of the routinely administered adolescent vaccines (Tdap, MenACWY, and HPV). Nationally, Healthy People 2010 vaccination objectives of 90% coverage among adolescents aged 13--15 years were met for ≥3 doses of HepB and ≥1 dose of VAR. Coverage with routine adolescent vaccines is increasing; however, more effort, including identification and dissemination of successful state-based practices, is needed to continue to increase the number of adolescents vaccinated according to ACIP recommendations.

NIS-Teen collects vaccination information regarding adolescents aged 13--17 years* in the 50 states and selected local areas† using a random-digit-dialed sample of telephone numbers of households. In 2009, the NIS-Teen was expanded to include adolescents living in the U.S. Virgin Islands (including St. Croix, St. Thomas, St. John, and Water Island). After parent/guardian respondents grant permission, surveys are mailed to the adolescents' vaccination providers to obtain vaccination histories. In 2009, the household response rate§ was 58.0%; a total of 20,399 adolescents with provider-verified vaccination records are included in this report, representing 57.2% of all adolescents with completed household interviews. A total of 20,066 adolescents (10,445 males and 9,621 females) are included in the national estimates.¶ NIS-Teen methodology, including the weighting procedure, has been described previously.** Statistical differences in vaccination coverage were evaluated using t-tests and were considered statistically significant at p≤0.05.

Vaccination coverage among adolescents increased substantially from 2008 to 2009. Among adolescents aged 13--17 years, administration of ≥1 dose of tetanus and diphtheria (Td) or Tdap vaccine after age 10 years increased from 72.2% to 76.2% (Table 1). Coverage with ≥1 dose of Tdap increased from 40.8% to 55.6%, and coverage with ≥1 dose of MenACWY increased from 41.8% to 53.6%. Among adolescent females, coverage with ≥1 dose of HPV increased from 37.2% to 44.3% and with ≥3 doses of HPV increased from 17.9% to 26.7%. At least 24 weeks between the first and third doses of the HPV vaccine are needed to complete the series (1). Among those who initiated the HPV series, 90.1% had received their first dose at least 24 weeks before the interview date and had the minimum period needed to complete the series before the interview. Of these, 67.5% (95% confidence interval [CI] = 64.4--70.5) received ≥3 doses. Among males, 49.6% (CI = 47.8--51.4) received both ≥1 dose of Td/Tdap and ≥1 dose of MenACWY; among females, 33.6% (CI = 31.8--35.4) received ≥1 dose of Td/Tdap, ≥1 dose of MenACWY, and ≥1 dose of HPV.

Among vaccines either administered during childhood or as catch-up adolescent vaccinations, coverage with ≥2 doses of MMR was similar to coverage during 2008 at 89.1%; coverage with ≥3 doses of HepB increased from 87.9% to 89.9% (Table 1). Reported history of varicella disease continued to decrease among adolescents from 59.8% to 52.7%. Among adolescents, 75.7% had protection from varicella disease (i.e., history of varicella or received ≥2 doses of VAR). Coverage with ≥2 doses of MMR, ≥3 doses of HepB, ≥1 dose of VAR, ≥2 doses of VAR, ≥1 dose of Tdap, and ≥1 dose of MenACWY differed by age, with generally lower rates among older age groups. However, coverage rates with ≥1 and ≥3 doses of HPV, and ≥1 dose of Td or Tdap, generally were higher among older than younger adolescents.

Coverage estimates varied by state and local area (Table 2) with rates ranging from 22.6% (Mississippi) to 76.6% (Colorado) for ≥1 doses of Tdap, from 19.3% (Mississippi) to 78.3% (District of Columbia) for ≥1 dose of MenACWY, and from 22.9% (Mississippi) to 69.0% (Massachusetts) for ≥1 dose of HPV. Four states (Connecticut, Massachusetts, New Hampshire, and Rhode Island) had coverage of >60% for all three routinely administered adolescent vaccines (Tdap, MenACWY, and HPV). Many states had a ≥15 percentage point increase from 2008 to 2009 in coverage for ≥1 dose of Tdap, ≥1 dose of MenACWY, or ≥1 dose of HPV. ††

No statistically significant differences were found in coverage with ≥1 dose of Tdap or MenACWY by racial/ethnic group§§ or by poverty status¶¶ (Table 3). For ≥1 dose of HPV, no differences were found in coverage by race/ethnicity; however, compared with those living at or above the poverty level, HPV initiation was higher among those living below the poverty level (51.9% versus 42.5%). Coverage with ≥3 doses of HPV was lower among blacks (23.1%) and Hispanics (23.4%) compared with whites (29.3%). Among vaccines either administered during childhood or as catch-up adolescent vaccinations, coverage with ≥2 doses of MMR was higher among whites than among blacks (90.2% versus 86.3%) and protection from varicella disease was higher among whites than among blacks (77.0% versus 71.3%). Having a history of varicella disease was higher among whites than among Hispanics (55.0% versus 50.1%). Coverage with ≥1 dose of VAR without history of disease was higher among those living at or above the poverty level (87.6% versus 82.9%); and, coverage with ≥1 dose of Td/Tdap was higher among those living at or above the poverty level (77.0% versus 71.8%).

Measured against the Healthy People 2010 targets of 90% coverage (3), vaccination coverage for adolescents aged 13--15 years was 89.0% (CI = 87.9--90.0) for ≥2 doses of MMR, 91.2% (CI = 90.3--92.1) for ≥3 doses of HepB, 74.7% (CI = 73.3--76.0) for ≥1 dose of Td/Tdap, and 90.5% (CI = 89.1--91.7) for ≥1 dose of VAR.

Reported by

C Dorell, MD, S Stokley, MPH, D Yankey, MS, A Cohn, MD, Immunization Svc Div, National Center for Immunization and Respiratory Diseases; L Markowitz, MD, Div of Sexually Transmitted Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Editorial Note

In 2009, vaccination coverage among adolescents aged 13--17 years increased substantially. As in 2008, adolescent vaccination coverage in 2009 also continued to vary widely among states and local areas, a variation that might be explained, in part, by different vaccination-promoting initiatives. Some of these initiatives include communication campaigns, strong partnerships with local professional organizations, universal funding of adolescent vaccinations, and middle school entry vaccination requirements. During the 2009--10 school year, for entry to middle school, 27 states required Tdap, seven required MenACWY, and two had requirements for HPV with opt-out provisions (4). Evaluation of vaccination-promoting initiatives, vaccine financing policies, and school requirements regarding Tdap, MenACWY, and HPV are ongoing and are needed to understand their impact on adolescent vaccination to promote effective state-based practices.

Although ≥1 dose HPV coverage was higher among Hispanics compared with whites in 2008 (2), no racial/ethnic differences for HPV initiation were observed in 2009. However, whites had higher completion rates compared with blacks and Hispanics, emphasizing that efforts are needed to ensure administration of 3 doses. Similar to 2008, a higher percentage of adolescent females living below the poverty level had initiated the HPV series than those living at or above poverty level. Although the ACIP-recommended age for HPV vaccination is 11 or 12 years, HPV coverage was higher among older compared with younger adolescent females in 2009. Some studies have found that parents and physicians prefer vaccinating older adolescent females (5,6), making education regarding HPV infection and the benefits of vaccination at the recommended age, before sexual activity begins, an important public health endeavor. Because of the complexity of factors associated with HPV vaccination, including sociodemographic characteristics, local vaccination funding and policies, and parental attitudes, further analyses are needed to understand how these factors affect HPV coverage.

Coverage with Tdap and MenACWY differed by age. Lower Tdap coverage among older adolescents might be attributed to several factors. For example, many older teens had received Td before licensure of Tdap. Because a 5-year interval is recommended between receipt of Td and Tdap, these adolescents were not yet eligible to receive Tdap*** (1). Lower MenACWY coverage among older adolescents can be attributed to at least two factors: limited availability of the vaccine during the first 2 years of MenACWY production (7) and fewer preventive health visits by adolescents as they get older, thus limiting the opportunities for catch-up vaccination.

The findings in this report are subject to at least three limitations. NIS-Teen is a landline telephone survey; although studies have shown no evidence of bias after adjusting sampling weights for noncoverage of households with no landline telephones in NIS-Teen, nonresponse and noncoverage bias might remain, leading to underestimation or overestimation of coverage rates (8). Second, underestimates of vaccination coverage might have resulted from the exclusive use of provider-verified vaccination histories because completeness of these records is unknown (9). Finally, estimates for particular states and local areas and for racial/ethnic populations should be interpreted with caution because of smaller sample sizes and wider confidence intervals.

Because adolescents are thought to be an important source of pertussis transmission, recent increases in pertussis cases exemplify the need to increase adolescent vaccination rates. In 2007, CDC launched a national campaign to promote parental awareness of adolescent vaccines and developed a program called It's Their Turn to support state health departments in their vaccination campaigns.††† The Vaccines for Children program provides free vaccine for children aged ≤18 years for families who might not be able to afford vaccine. However, additional strategies are needed to increase coverage among adolescents. Evaluation of vaccination policies and practices associated with higher coverage in certain states and areas can help characterize effective methods. Patient reminders by health-care providers can promote preventive health-care visits and vaccinations among adolescents (10). Urging the public and health-care providers to view every health visit as an opportunity for vaccination will decrease missed opportunities to provide vaccines (10). Additionally, exploration of using nontraditional settings to increase vaccination coverage (e.g., schools) should continue.

References

1. CDC. Recommended immunization schedules for persons aged 0 through 18 years---United States, 2010. MMWR 2010;58(51&52).
2. CDC. National, state, and local area vaccination coverage among adolescents aged 13--17 years---United States, 2008. MMWR 2009;58:997--1001.
3. US Department of Health and Human Services. Objective 14-27: increase routine vaccination coverage levels for adolescents. Healthy People 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/html/objectives/14-27.htm. Accessed August 13, 2010.
4. Knighton C, Thomas E, Stanwyck C. School-entry vaccination laws in the United States, 2009--2010: a brief overview. Presented at 44th National Immunization Conference, April 19--22, 2010, Atlanta, GA.
5. Dempsey AF, Abraham LM, Dalton V, Ruffin M. Understanding the reasons why mothers do or do not have their adolescent daughters vaccinated against human papillomavirus. Ann Epidemiol 2009;19:531--8.
6. Daley MF, Crane LA, Markowitz LE, et al. Human papillomavirus vaccination practices: survey of US physicians 18 months after licensure. Pediatrics, August 2, 2010. Epub ahead of print.
7. CDC. Limited supply of meningococcal conjugate vaccine, recommendation to defer vaccination of persons aged 11--12 years. MMWR 2006;55:567--8.
8. Copeland K, Dorell C, Khare M, Ormson AE, Wouhib A. Assessment of bias in the National Immunization Survey-Teen: an updated benchmark to the National Health Interview Survey. Presented at the 65th Annual American Association for Public Opinion Research Conference, May 13--16, 2010, Chicago, IL.
9. Stokley S, Rodewald LE, Maes EF. The impact of record scattering on the measurement of immunization coverage. Pediatrics 2001;107:91--6.
10. Committee on Practice and Ambulatory Medicine and Council on Community Pediatrics. Policy statement: increasing immunization coverage. Pediatrics 2010;125:1295--1304.

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