Teen Vaccination Coverage in the United States, 2018

This report describes vaccination coverage among U.S. teenagers in 2018. The survey behind it runs every year, so later years have their own estimates.

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination at ages 11–12 to protect against certain diseases, including cancers caused by human papillomavirus (HPV), meningococcal disease and pertussis. It recommends a booster dose of the quadrivalent meningococcal conjugate vaccine (MenACWY) at 16, and serogroup B meningococcal vaccine (MenB) may be given at ages 16–23.

To measure how many teens were vaccinated, CDC used the 2018 National Immunization Survey–Teen (NIS-Teen). The survey reaches parents and guardians by calling a random sample of cell phone numbers, asks permission to contact the teen's vaccination providers, and then mails those providers a questionnaire about the teen's medical record. The 2018 estimates cover 18,700 teens aged 13–17 (8,928 girls and 9,772 boys) with adequate provider records.

The national picture

Vaccination coverage among teens aged 13–17, by vaccine and dose, NIS-Teen, 2006–2018. Vertical lines mark a revised definition of adequate provider data (2013) and the start of estimates from a cell-phone-only sample. CDC.

From 2017 to 2018:

• HPV, at least one dose: rose from 65.5% to 68.1%.
• HPV, up to date with the series: rose from 48.6% to 51.1%. The gain came from boys alone: up 4.4 percentage points among boys, against 0.6 among girls.
• MenACWY, at least one dose: rose 1.5 points to 86.6%.
• MenACWY, two or more doses (17-year-olds): rose 6.5 points to 50.8%.
• Tdap (tetanus, diphtheria and pertussis): stable at 89%.
• MenB, at least one dose (17-year-olds): 17.2%.

Coverage with three or more hepatitis B doses, two or more measles, mumps and rubella doses, and one or two varicella doses did not change significantly. From 2014 through 2018, coverage with at least one HPV dose rose by an average of 4.4 percentage points a year.

Gaps by place and insurance

Teens living outside metropolitan statistical areas (MSAs) had lower coverage than teens in the principal cities of MSAs for every HPV and MenACWY measure and for two varicella doses. The largest gaps were in being up to date with HPV (15.4 percentage points) and in two-dose MenACWY (19.7 points). Teens in other parts of metropolitan areas also trailed principal cities on HPV, by 5.3 points for one dose and 7.0 points for being up to date, and on hepatitis B, by 1.7 points.

Teens with Medicaid had higher HPV coverage than those with private insurance, by 8.8 points for one dose and 5.5 for being up to date. Uninsured teens had lower coverage than privately insured teens on every measure, from 4.4 points lower for one varicella dose to 18.7 points lower for two MenACWY doses. Uninsured teens can get vaccines free through the Vaccines for Children (VFC) program, which also covers those who are Medicaid-eligible or American Indian or Alaska Native, but some parents do not know about it or think it serves only infants and young children. The authors suggest practices routinely check patients' eligibility and tell families about the program.

What a recommendation does

Overall, 77.5% of parents said a health care provider had recommended the HPV vaccine for their teen. That ranged by state from 59.5% in Mississippi to 90.7% in Massachusetts, and parents outside metropolitan areas reported a recommendation less often than those in principal cities (70.3% versus 77.4%). Teens whose parents got a recommendation were far more likely to have at least one HPV dose: 74.7%, against 46.7% for those whose parents did not.

Even with a recommendation, only 75% accepted the vaccine, which suggests other reasons are also at work. The authors call for helping providers make strong recommendations that stress HPV vaccination as cancer prevention and address parents' concerns, especially in states and rural areas where recommendations were less common. In one study, parents in the rural South said they lacked information about the vaccine and its purpose. CDC offers resources and videos showing how to give a recommendation.

Why HPV matters

The authors found the continued rise among boys encouraging and the lack of any rise among girls concerning. An estimated 34,800 cancers caused by HPV occur in the United States each year, and 32,100 of them (92%) could be prevented by the 9-valent HPV vaccine. HPV vaccination has already brought large drops in infections with the vaccine's HPV types among adolescent girls and young adults, and fewer cervical precancers.

Limits of the data

The survey's response rate was 23.3%, and fewer than half (48.3%) of teens with completed interviews had adequate provider data. Some bias may remain after weighting. Because the survey switched in 2018 from landline and cell phone samples to cell phones alone, changes from 2017 should be read with caution. State estimates may rest on small samples, some differences may be due to chance, two-dose MenACWY and MenB coverage may be underestimated because those doses can come after age 17, and parents' reports of a recommendation may be affected by recall.

Sources

• Walker TY, Elam-Evans LD, Yankey D, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2018. MMWR Morb Mortal Wkly Rep 68(33). https://www.cdc.gov/mmwr/volumes/68/wr/mm6833a2.htm
• CDC, HPV vaccine resources for health care providers: https://www.cdc.gov/vaccines/vpd/hpv/hcp/resources.html
• CDC, Vaccines for Children eligibility: https://www.cdc.gov/vaccines/programs/vfc/providers/eligibility.html