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National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2013

National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged... Morbidity and Mortality Weekly Report National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2013 1 1 1 1 1 Laurie D. Elam-Evans, PhD , David Yankey, MS , Jenny Jeyarajah, MS , James A. Singleton, PhD , C. Robinette Curtis, MD , 2 3 Jessica MacNeil, MPH , Susan Hariri, PhD (Author affiliations at end of text) The Advisory Committee on Immunization Practices state met the target for ≥3 HPV doses. Use of patient reminder (ACIP) recommends that adolescents routinely receive 1 dose and recall systems, immunization information systems, cover- of tetanus toxoid, reduced diphtheria toxoid, and acellular age assessment and feedback to clinicians, clinician reminders, pertussis (Tdap) vaccine, 2 doses of meningococcal conjugate standing orders, and other interventions can help make use (MenACWY) vaccine, and 3 doses of human papillomavirus of every health care visit to ensure that adolescents are fully (HPV) vaccine (1,2).* ACIP also recommends administration protected from vaccine-preventable infections and cancers (5), of “catch-up” vaccinations, such as measles, mumps, and especially when such interventions are coupled with clinicians’ rubella (MMR), hepatitis B, and varicella, and, for all persons vaccination recommendations. aged ≥6 months, an annual influenza vaccination (1). ACIP Vaccination coverage was assessed using 2013 NIS-Teen data recommends administration of all age-appropriate vaccines for adolescents aged 13–17 years in the 50 states, the District during a single visit (3). To assess vaccination coverage among of Columbia, selected local areas,** Guam, and the U.S. Virgin adolescents aged 13–17 years, CDC analyzed data from the Islands, using a random-digit–dialed sample of landline and § †† 2013 National Immunization Survey-Teen (NIS-Teen). This cell phones. Telephone interviews were conducted with the report summarizes the results of that analysis, which show that parent or guardian of age-eligible adolescents to obtain infor- from 2012 to 2013, coverage increased for each of the vaccines mation about the adolescent’s demographic characteristics and §§ routinely recommended for adolescents: from 84.6% to 86.0% to request vaccination provider contact information. After for ≥1 Tdap dose; from 74.0% to 77.8% for ≥1 MenACWY receiving a respondent’s consent, a questionnaire was mailed dose; from 53.8% to 57.3% for ≥1 HPV dose among females, to each vaccination provider to obtain provider-confirmed and from 20.8% to 34.6% for ≥1 HPV dose among males. immunization information. In 2013, national estimates were Coverage varied by state and local jurisdictions and by U.S. based on responses for 18,264 adolescents (8,710 females and Department of Health and Human Services (HHS) region. Healthy People 2020 vaccination targets for adolescents aged HP2020 objectives and targets were established for females only in 2010 (4), before ACIP’s 2011 recommendation for routine use of the quadrivalent HPV 13–15 years (4) were reached in 42 states for ≥1 Tdap dose, vaccine among males aged 11–12 years (2). In April 2014, the federal HP2020 18 for ≥1 MenACWY dose, and 11 for ≥2 varicella doses. No work group approved a new HP2020 objective to reach an 80% vaccination target with 3 doses of HPV vaccine among adolescent males aged 13–15 years (Office of Policy, Office of the Director, National Center for Immunization * Adolescents who receive their first MenACWY vaccine dose as routinely and Respiratory Diseases, CDC, unpublished data, April 2014). recommended at age 11–12 years should receive a second dose at 16 years. ** Local areas that received Federal Section 317 immunization funds were Adolescents who receive their first dose at ages 13–15 years should receive a sampled separately: Chicago, Illinois; New York, New York; Philadelphia second dose at age 16–18 years, with a minimum interval of ≥8 weeks between County, Pennsylvania; Bexar County, Texas; and Houston, Texas. †† doses. Adolescents who receive a MenACWY vaccine dose at age ≥16 years do All identified cell phone households were eligible for interview. Sampling not need a second dose. weights adjusted to correct for dual-frame (landline and cell phone) sampling, Catch-up vaccination is recommended for some vaccines routinely nonresponse, noncoverage, and overlapping samples of mixed telephone users. recommended in childhood. MMR vaccine is recommended for any adolescents A description of NIS-Teen dual-frame survey methodology and its effect on who have not had 2 doses of MMR vaccine. Catch-up vaccination for varicella reported vaccination estimates is available at http://www.cdc.gov/vaccines/ is recommended for persons aged 7–18 years without evidence of immunity stats-surv/nis/dual-frame-sampling-082812.htm. §§ (MMWR 2007;56 [No. RR-4]). Adolescents should have received 2 doses of The Council of American Survey Research Organizations (CASRO) response varicella vaccine. Catch up vaccination for hepatitis B is recommended for any rate for the landline and cell phone samples were 51.1% and 23.3%, unvaccinated persons, and they should complete a 3-dose series. However, a respectively. For completed interviews, 6,039 by landline (59.5%) and 12,225 2-dose series (doses separated by at least 4 months) of adult formulation by cell phone (54.5%) had adequate provider data. Overall, 33% of completed Recombivax HB is licensed for use in children aged 11–15 years (1). interviews with adequate provider data were from landlines, and 67% were Eligible participants were born during January 1995–February 2001. Except from cell phones. For USVI, the landline and cell phone sample CASRO rate as noted, coverage for ≥1 and ≥2 varicella doses were obtained among persons was 60.6% and 31.5%, respectively. For Guam, landline and cell phone sample with no history of varicella disease. HPV vaccination coverage represents receipt CASRO was 45.6% and 21.0%, respectively. The CASRO response rate is of any HPV vaccine and does not distinguish between bivalent or quadrivalent the product of three other rates: 1) the resolution rate (the proportion of vaccines. Some adolescents, both males and females, might have received more telephone numbers that can be identified as either for business or residence), than the 3 recommended HPV doses. Influenza vaccination coverage estimates 2) the screening rate (the proportion of qualified households that complete are not included in this report but are available online at http://www.cdc.gov/ the screening process), and 3) the cooperation rate (the proportion of contacted flu/fluvaxview/index.htm. eligible households for which a completed interview is obtained). MMWR / July 25, 2014 / Vol. 63 / No. 29 625 Morbidity and Mortality Weekly Report ¶¶ 9,554 males). Details of NIS-Teen methodology, including National Vaccination Coverage methods for synthesizing provider-reported immunization During 2006–2013, NIS-Teen data show that coverage histories and weighting, have been described previously.*** trends differed substantially for Tdap, MenACWY, and HPV NIS-Teen data from 2006–2013 were used in this report vaccination (Figure). Coverage estimates for ≥1 Tdap dose and to describe vaccination coverage over time. Weighted linear ≥1 MenACWY dose increased significantly each year from ††† regression was used to assess coverage trends for vaccines 2006 to 2013, with average increases of 10.4 percentage points recommended routinely for adolescents. T-tests were used to (95% confidence interval [CI] = 7.8–13.1) for Tdap and 8.9 assess vaccination coverage differences by survey year (2013 percentage points (CI = 6.5–11.3) for MenACWY. Coverage compared with 2012), age, sex, race/ethnicity, and poverty for ≥1 HPV dose increased an average of 4.5 percentage points status for all vaccines included in this report. Results were (CI = 2.7–6.3) annually from 2007 to 2013 for females, and considered statistically significant at p<0.05. by 9.9 percentage points (CI = 4.8–15.0) from 2010 to 2013 for males. In 2013, Tdap and MenACWY coverage estimates were 86.0% and 77.8%, respectively (Table 1). From 2012 ¶¶ Adolescents from the U.S. Virgin Islands (156 females and 176 males) and from Guam (164 females and 199 males) were excluded from the national estimates. to 2013, coverage with ≥1, ≥2, and ≥3 HPV doses increased *** Additional information available at ftp://ftp.cdc.gov/pub/health_statistics/ for both sexes. Coverage with ≥1 HPV dose in 2013 was nchs/dataset_documentation/nis/nisteenpuf12_dug.pdf. ††† 57.3% for females and 34.6% for males. No statistically sig- Annual estimates of vaccination coverage were regressed on survey year via a weighted linear regression, with regression weights calculated using the nificant changes occurred from 2012 to 2013 in coverage for inverse of the estimated variance of the vaccination coverage point estimate. ≥2 doses of MMR vaccine or ≥3 doses of hepatitis B vaccine. However, coverage for ≥2 doses of varicella vaccine increased FIGURE. Estimated vaccination coverage with selected vaccines and doses among adolescents aged 13–17 years, by survey year — National Immunization Survey-Teen, United States, 2006–2013 Tdap* MenACWY ≥1 HPV (females) ≥3 HPV (females) ≥1 HPV (males) ≥3 HPV (males) 2006 2007 2008 2009 2010 2011 2012 2013 Survey year Abbreviations: Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus. * ≥1 dose Tdap vaccine on or after age 10 years. ≥1 dose MenACWY vaccine. HPV vaccine, either bivalent or quadrivalent, among females. The Advisory Committee on Immunization Practices (ACIP) recommends either bivalent or quadrivalent vaccine for females. HPV vaccine, either bivalent or quadrivalent, among males. ACIP recommends the quadrivalent vaccine for males; however, some males might have received bivalent vaccine. 626 MMWR / July 25, 2014 / Vol. 63 / No. 29 % vaccinated Morbidity and Mortality Weekly Report TABLE 1. Estimated vaccination coverage with selected vaccines among adolescents aged 13–17 years,* by age at interview — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Age at interview (yrs) Total 13 14 15 16 17 2013 2012 (n = 3,735) (n = 3,841) (n = 3,645 ) (n = 3,783 ) (n = 3,260 ) (N = 18,264 ) (N = 19,199 ) Vaccine % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) § ¶ Tdap ≥ 1 dose 87.2 (±1.9) 87.0 (±2.1) 88.4 (±1.7) 84.3 (±2.1) 83.0 (±2.7) 86.0 (±0.9)** 84.6 (±0.9) †† ¶ MenACWY ≥1 dose 76.1 (±2.4) 78.2 (±2.3) 80.0 (±2.3) 77.8 (±2.5) 76.7 (±2.9) 77.8 (±1.1)** 74.0 (±1.1) §§ HPV vaccination Females ¶ ¶ ¶ ≥1 dose 50.6 (±4.1) 55.1 (±4.2) 58.8 (±4.3) 60.0 (±4.5) 62.3 (±4.5) 57.3 (±1.9)** 53.8 (±1.9) ¶ ¶ ¶ ≥2 dose 39.2 (±4.2) 43.3 (±4.2) 48.7 (±4.5) 51.1 (±4.6) 56.8 (±4.5) 47.7 (±2.0)** 43.4 (±1.9) ¶ ¶ ¶ ¶ ≥3 doses 25.8 (±3.8) 32.1 (±3.9) 39.4 (±4.6) 43.1 (±4.5) 48.2 (±4.5) 37.6 (±1.9)** 33.4 (±1.7) Males ≥1 dose 33.5 (±4.5) 35.1 (±4.4) 36.2 (±4.1) 35.9 (±4.0) 32.1 (±4.1) 34.6 (±1.9)** 20.8 (±1.5) ≥2 dose 23.4 (±4.3) 24.3 (±4.0) 23.8 (±3.8) 23.2 (±3.7) 22.9 (±3.5) 23.5 (±1.7)** 12.7 (±1.3) ≥3 doses 11.7 (±2.7) 13.6 (±3.3) 15.3 (±3.5) 13.7 (±3.1) 15.1 (±3.0) 13.9 (±1.4)** 6.8 (±1.0) §§ HPV 3-dose series ¶¶ completion ¶ ¶ ¶ Females 56.1 (±6.7) 64.7 (±5.7) 72.1 (±5.0) 75.9 (±5.6) 79.5 (±4.6) 70.4 (±2.5)** 66.7 (±2.6) Males 41.6 (±9.4) 47.1 (±9.3) 51.0 (±8.7) 48.8 (±8.2) 53.4 (±8.5) 48.3 (±4.0) 45.1 (±5.0) MMR*** ≥2 doses 92.6 (±1.4) 93.1 (±1.4) 91.4 (±2.1) 92.0 (±1.6) 89.7 (±2.3) 91.8 (±0.8) 91.4 (±0.8) Hepatitis B ≥3 doses 94.7 (±1.3) 94.0 (±1.3) 92.5 (±1.9) 93.1 (±1.5) 91.4 (±2.2) 93.2 (±0.7) 92.8 (±0.7) Varicella ††† ¶ ¶ ¶ ¶ History of varicella 15.6 (±2.1) 19.5 (±2.4) 25.1 (±2.5) 30.6 (±2.8) 37.1 (±3.0) 25.4 (±1.2)** 30.6 (±1.2) Among adolescents with no history of varicella ¶ ¶ ¶ ¶ ≥1 dose vaccine 97.4 (±0.8) 95.4 (±1.6) 94.6 (±2.0) 94.0 (±1.9) 91.9 (±3.3) 94.9 (±0.9) 94.7 (±0.8) ¶ ¶ ¶ ≥2 doses vaccine 83.1 (±2.2) 80.2 (±2.5) 78.7 (±3.0) 76.6 (±3.1) 71.6 (±4.0) 78.5 (±1.3)** 74.9 (±1.4) History of varicella or 85.7 (±1.9) 84.1 (±2.1) 84.0 (±2.3) 83.7 (±2.3) 82.2 (±2.8) 84.0 (±1.0) 82.6 (±1.0) received ≥2 doses varicella vaccination Abbreviations: CI = confidence interval; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus; MMR = measles, mumps, and rubella. * Adolescents (N = 18,264) in the 2013 NIS-Teen were born January 11, 1995, through February 13, 2001. Estimates for overall NIS-Teen data for 2012 are provided as a comparison with overall 2013 NIS-Teen data. Includes percentages receiving Tdap vaccine at or after age 10 years. Statistically significant difference (p<0.05) in estimated vaccination coverage by age: reference group was adolescents aged 13 years. ** Statistically significant difference (p<0.05) compared with 2012 NIS-Teen overall estimates. †† Includes percentages receiving MenACWY or meningococcal-unknown type vaccine. §§ HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. Percentage reported among females (n = 8,710) and males (n = 9,554). Some adolescents might have received more than the recommended 3 doses of HPV vaccine. ¶¶ The completion rate for the 3-dose HPV vaccination series represents the percentage of adolescents who received ≥3 doses among those who had ≥1 HPV vaccine dose with at least 24 weeks between the first dose and the interview date. The calculation was limited to 4,611 females and 2,580 males who met the criteria of having received ≥1 HPV vaccine dose and having at least 24 weeks between the first dose and the interview date. *** ≥2 doses of MMR vaccine. ††† By parent/guardian report or provider records. from 74.9% to 78.5% among adolescents with no history of Vaccination Coverage by Selected Characteristics disease (Table 1). In 2013, among females, ≥1 HPV dose coverage was signifi- Coverage with the second MenACWY dose was calculated cantly higher among adolescents aged 15–17 years compared as the proportion of adolescents aged 17 years on date of with younger adolescents (Table 1). However, ≥1 HPV dose interview who received a second MenACWY dose on or after coverage for males did not vary by age. In 2013, as found their 16th birthday, among those who had received a first previously, most vaccination coverage rates were similar by dose before their 16th birthday (only second doses received sex; however, females had greater vaccination coverage than on or after their 16th birthday and at least 8 weeks after the males for ≥1, ≥2, and ≥3 HPV doses and 3-dose HPV series §§§ first dose were counted). All of these adolescents were aged 16 completion (Table 1). Also, females had significantly higher years after the MenACWY second dose was recommended by §§§ ACIP in October 2010 (n = 2,310) (6). The MenACWY 2-dose The completion rate for 3-dose HPV vaccination series represents the percentage of adolescents who received ≥3 doses among those who had ≥1 completion rate was 29.6% (CI = 26.4%–33.0%). HPV dose and ≥24 weeks between the first dose and the interview date. MMWR / July 25, 2014 / Vol. 63 / No. 29 627 Morbidity and Mortality Weekly Report vaccination coverage than males for ≥2 varicella doses (80.0% coverage was higher among Hispanic compared with white [CI = 78.1%–81.7%] versus 77.2% [CI = 75.2%–79.0%]). adolescents. Among males, ≥1, ≥2, and ≥3 HPV dose coverage In 2013, there were no racial or ethnic differences in vac- was higher among black and Hispanic adolescents compared cination coverage for ≥1 Tdap, ≥3 hepatitis B, or ≥2 varicella with white adolescents. Black adolescent females had lower (Table 2). However, ≥1 MenACWY dose coverage was higher HPV 3-dose series completion compared with white adolescent among Hispanic and Asian adolescents compared with white females and, in contrast to findings in 2012, series comple- adolescents. Among females, ≥1, ≥2, and ≥3 HPV dose tion among Hispanic females was similar to coverage among † § TABLE 2. Estimated vaccination coverage among adolescents aged 13–17 years,* by race/ethnicity, poverty level, and selected vaccines and doses — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Race/Ethnicity Poverty status American Indian/ White, non- Black, Alaska Native, Asian, Below poverty At or above Hispanic non-Hispanic Hispanic non-Hispanic non-Hispanic Multiracial level poverty level (n = 12,064) (n = 1,647 ) (n = 2,741 ) (n = 284) (n = 561 ) (n = 886 ) (n = 3,078 ) (n = 14,754) Vaccines % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Tdap** ≥1 dose 85.9 (±1.1) 84.1 (±3.0) 87.1 (±2.4) 85.3 (±7.2) 89.7 (±3.6) 85.4 (±4.9) 85.2 (±2.3) 86.4 (±1.0) †† §§ §§ MenACWY ≥1 dose 75.6 (±1.3) 77.0 (±3.3) 83.4 (±2.8) 71.7 (±11.1) 83.8 (±7.1) 76.3 (±5.1) 78.4 (±2.6) 77.5 (±1.2) ¶¶ HPV vaccination Females §§ §§ §§ ≥1 dose 53.1 (±2.3) 55.8 (±5.2) 67.5 (±5.0) 73.3 (±14.7) 57.0 (±11.4) 57.6 (±9.3) 66.8 (±4.3) 54.6 (±2.2) §§ §§ ≥2 dose 44.0 (±2.2) 45.6 (±5.2) 57.7 (±5.4) 57.3 (±15.2) 47.2 (±11.2) 46.2 (±9.5) 55.2 (±4.6) 45.3 (±2.2) §§ ≥3 doses 34.9 (±2.1) 34.2 (±4.8) 44.8 (±5.6) 43.2 (±14.2) 40.4 (±11.0) 40.3 (±9.3) 41.5 (±4.6) 36.4 (±2.1) Males §§ §§ §§ §§ ≥1 dose 26.7 (±1.9) 42.2 (±5.5) 49.6 (±5.2) 38.6 (±14.0) 26.3 (±8.9) 34.5 (±7.3) 46.7 (±4.5) 30.8 (±2.0) §§ §§ §§ ≥2 dose 18.5 (±1.7) 27.5 (±4.8) 34.5 (±5.3) 24.8 (±11.4) 19.5 (±8.0) 19.1 (±5.2) 28.7 (±4.0) 22.0 (±1.9) §§ §§ §§ ≥3 doses 11.1 (±1.3) 15.7 (±3.8) 20.3 (±4.5) NA NA 9.1 (±4.5) 12.5 (±4.2) 16.7 (±3.0) 13.0 (±1.6) ¶¶ HPV 3-dose series completion*** §§ Females 71.8 (±2.9) 63.7 (±7.3) 69.5 (±6.1) 60.1 (±16.9) 77.2 (±12.1) 75.1 (±13.8) 66.2 (±5.7) 71.9 (±2.8) Males 51.1 (±4.7) 44.8 (±8.8) 47.4 (±9.0) 48.4 (±20.0) 40.0 (±18.8) 49.3 (±13.9) 44.3 (±7.2) 50.4 (±4.8) ††† §§ MMR ≥2 doses 92.8 (±0.8) 91.1 (±2.4) 90.2 (±2.3) 93.5 (±5.2) 90.8 (±6.0) 89.8 (±3.7) 91.7 (±1.7) 91.8 (±0.9) Hepatitis B ≥3 doses 93.8 (±0.8) 93.2 (±2.1) 92.8 (±2.0) 93.4 (±5.3) 87.8 (±6.6) 91.7 (±3.1) 93.2 (±1.6) 93.1 (±0.9) Varicella §§§ §§ §§ §§ History of varicella 26.8 (±1.4) 22.6 (±3.5) 24.6 (±3.0) 36.6 (±10.6) 24.2 (±6.7) 18.5 (±3.9) 29.0 (±3.0) 24.0 (±1.2) Among adolescents with no history of varicella ≥1 dose vaccine 95.3 (±0.8) 94.3 (±2.6) 94.5 (±2.5) 95.7 (±3.7) 94.3 (±6.7) 94.4 (±3.0) 94.7 (±1.9) 95.2 (±1.0) ≥2 dose vaccine 77.7 (±1.5) 77.9 (±3.6) 80.3 (±3.5) 78.7 (±9.8) 85.2 (±8.1) 76.7 (±6.4) 77.3 (±3.0) 79.0 (±1.5) History of varicella or 83.7 (±1.1) 82.9 (±3.0) 85.2 (±2.7) 86.5 (±6.4) 88.8 (±6.3) 81.0 (±5.4) 83.8 (±2.3) 84.0 (±1.1) received ≥2 doses varicella vaccination Abbreviations: CI = confidence interval; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus; NA = not available (estimate not reported because unweighted sample size for the denominator was <30 or 95% CI half width/estimate >0.6); MMR = measles, mumps, and rubella. * Adolescents (N = 18,264) in the 2013 NIS-Teen were born January 11, 1995, through February 13, 2001. Adolescent’s race/ethnicity was reported by parent or guardian. Adolescents identified in this report as white, black, Asian, American Indian/Alaska Native or multiracial were reported by the parent or guardian as non-Hispanic. Adolescents identified as multiracial had more than one race category selected. Adolescents identified as Hispanic might be of any race. Native Hawaiian or other Pacific Islanders were not included in the table because of small sample sizes. 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 http://www.census.gov/hhes/ www/poverty.html. Poverty status was unknown for 432 adolescents. Estimates with 95% CI half-widths >10 might not be reliable. ** Includes percentages receiving Tdap vaccine at or after age 10 years. †† Includes percentages receiving MenACWY and meningococcal-unknown type vaccine. §§ Statistically significant difference (p<0.05) in estimated vaccination coverage by race/ethnicity or poverty level; referent groups were non-Hispanic white adolescents and adolescents living at or above poverty level, respectively. ¶¶ HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. Percentage reported among females (n = 8,710) and males (n = 9,554). Some adolescents might have received more than the 3 recommended HPV vaccine doses. *** The completion rate for the 3-dose HPV vaccination series represents the percentage of adolescents who received ≥3 doses among those who had ≥1 HPV vaccine dose with at least 24 weeks between the first dose and the interview date. The calculation was limited to 4,611 females and 2,580 males who met the criteria of having received ≥1 HPV vaccine dose and having ≥24 weeks between the first dose and the interview date. ††† Includes ≥2 doses of MMR vaccine. §§§ By parent/guardian report or provider records. 628 MMWR / July 25, 2014 / Vol. 63 / No. 29 Morbidity and Mortality Weekly Report white adolescent females. There were no statistically significant (CI = 30.3%–35.2%) for ≥3 HPV doses (among females), and racial/ethnic differences among males for HPV 3-dose series 80.7% (79.2%–82.1%) for ≥2 varicella doses. From 2012 to completion. In 2013, vaccination coverage did not vary by 2013, vaccination coverage for these national targets increased ¶¶¶ poverty level for ≥1 Tdap, ≥1 MenACWY, ≥2 MMR, ≥ 3 by 2.2–4.6 percentage points. The number of states meeting hepatitis B, ≥2 varicella, or HPV 3-dose series completion (for or exceeding the target was 42 for ≥1 Tdap dose (up from 36 males or females) (Table 2). However, those living below the in 2012), 18 for ≥1 MenACWY dose (up from 12 in 2012), poverty level had higher ≥1, ≥2, and ≥3 HPV dose coverage 11 for ≥2 varicella doses (up from 9 in 2012), and for ≥3 HPV (for males) and ≥1 and ≥2 HPV dose coverage (for females), doses among females, none. compared with their counterparts living at or above the poverty Discussion level. These findings in 2013 data that females had no differ- ence in 3-dose HPV completion by poverty status were not From 2012 to 2013, coverage for adolescents aged 13–17 observed in 2012 (7). years increased for all vaccinations routinely recommended for adolescents, with increases ranging from 1.4 percentage points State and Regional Vaccination Coverage for ≥1 Tdap dose to 13.8 percentage points for ≥1 HPV dose in males. Nationally, the Healthy People 2020 vaccination cov- In 2013, there was wide variation among states in cover- erage target for adolescents aged 13–15 years was reached for age (Table 3). Coverage for ≥1 Tdap ranged from 60.2% Tdap (87.5%) for the third survey year, and progress continues (Mississippi) to 95.5% (Rhode Island), whereas coverage for MenACWY (78.1%) and varicella (80.7%). These high estimates for ≥1 MenACWY ranged from 40.4% (Arkansas) vaccination coverage levels confirm that established targets of to 93.7% (North Dakota). Among females, coverage for ≥1 80%–90% are achievable for adolescents for vaccination and HPV doses ranged from 39.9% (Kansas) to 76.6% (Rhode vaccination series, just as they are for young children. However, Island) and for ≥3 HPV doses ranged from 20.5% (Utah) to coverage for ≥3 HPV doses among females aged 13–15 years 56.5% (Rhode Island). For males, coverage for ≥1 HPV doses in 2013 was 32.7%, and trends measured by 2013 and earlier ranged from 11.0% (Utah) to 69.3% (Rhode Island) and for NIS-Teen data demonstrate that the 80% Healthy People 2020 ≥3 HPV doses ranged from 7.3% (Nevada) to 43.2% (Rhode target will be difficult to achieve without changes in clinical Island). Coverage for ≥2 MMR doses ranged from 83.2% practices, leaving adolescents vulnerable to develop the cancers (West Virginia) to 97.4% (New Hampshire and Louisiana). that safe, effective HPV vaccines can prevent. Accelerating Coverage for ≥2 varicella doses ranged from 50.6% (South progress in HPV vaccination will require the collaboration of Dakota) to 95.8% (Connecticut). numerous stakeholders (e.g., clinicians, parents, adolescents, Coverage with ≥1 HPV doses in females increased from 2012 and public health professionals) to overcome barriers to use of to 2013 in five states (Illinois, Michigan, New Hampshire, New HPV vaccines (8). A variety of factors, including knowledge, Mexico, and South Carolina), with percentage point increases attitudes, and behaviors among clinicians and parents likely ranging from 12.0 (Illinois) to 18.5 (South Carolina). HPV contribute to lower HPV vaccination initiation compared coverage with ≥1 doses in females also increased by 6.0 percent- with Tdap and MenACWY vaccinations. Addressing barri- age points (CI = 0.1–12.0) in HHS Region IV (southeastern ers to HPV vaccination at the recommended ages of 11–12 states) and by 7.8 percentage points (CI = 2.1–13.4) in HHS years could reduce missed opportunities to administer all Region V (north central states) (Table 3). recommended adolescent vaccines during the same clinical encounter. Another analysis of 2013 NIS-Teen data indicates Healthy People 2020 Targets that for adolescent females born in 2000, coverage with at least The Healthy People 2020 national targets for vaccination 1 dose of HPV vaccine before age 13 years could have reached coverage among adolescents aged 13–15 years are 80.0% 91.3% if opportunities to administer HPV vaccine when other for ≥1 Tdap dose, ≥1 MenACWY dose, and ≥3 HPV doses vaccines were given had not been missed (9). (among females) and 90.0% for ≥2 varicella doses (4). Among Although HPV vaccination of adolescent females increased adolescents aged 13–15 years, vaccination coverage in 2013 by only 3.5 percentage points from 2012 to 2013, this increase was 87.5% (CI = 86.4%–88.6%) for ≥1 Tdap dose, 78.1% was significantly greater than that observed from 2011 to 2012, (CI = 76.7%–79.4%) for ≥1 MenACWY dose, 32.7% when first dose HPV coverage among adolescent females stag- ¶¶¶ nated. Whether increased health promotion activities aimed Adolescents were classified as below the federal poverty level if their family’s total income was less than the federal poverty level specified for their family at clinicians (e.g., http://www.cdc.gov/vaccines/youarethekey) size and number of children aged <18 years. All others were classified as at or and parents initiated during 2013 account for the modest above the poverty level. Poverty status was unknown for 432 adolescents. Additional information available at http://www.census.gov/hhs/www/poverty. increase is not known. Vaccination coverage increases in 2013 MMWR / July 25, 2014 / Vol. 63 / No. 29 629 Morbidity and Mortality Weekly Report TABLE 3. Estimated vaccination coverage with selected vaccines and doses* among adolescents aged 13–17 years by HHS region and state/ selected local area — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Females (n = 8,264) Males (n = 9,554) § ¶ †† §§ ¶¶ §§ ¶¶ ≥2 MMR ≥2 VAR ≥1 Tdap** ≥1 MenACWY ≥1 HPV ≥2 HPV ≥3 HPV*** ≥1 HPV ≥2 HPV ≥3 HPV*** Regional/State/ ††† Local area % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) §§§ §§§ §§§ §§§ §§§ §§§ §§§ §§§ §§§ United Sates overall 91.8 (±0.8) 78.5 (±1.3) 86.0 (±0.9) 77.8 (±1.1) 57.3 (±1.9) 47.7 (±2.0) 37.6 (±1.9) 34.6 (±1.9) 23.5 (±1.7) 13.9 (±1.4) §§§ §§§ §§§ HHS Region I 95.7 (±1.4) 90.9 (±2.3) 92.7 (±1.7) 87.7 (±2.1) 61.9 (±4.6) 51.8 (±4.8) 41.8 (±4.7) 51.4 (±4.6) 36.9 (±4.5) 23.0 (±3.9) §§§ §§§ §§§ Connecticut 97.3 (±2.4) 95.8 (±3.2) 90.8 (±4.3) 90.6 (±4.2) 56.0 (±9.2) 49.0 (±9.3) 40.1 (±9.1) 52.3 (±9.2) 36.4 (±8.9) 23.4 (±7.9) ¶¶¶ §§§ §§§ Maine 88.8 (±4.4) 71.0 (±7.2) 83.0 (±4.7) 71.2 (±5.6) 60.2 (±8.8) 55.4 (±8.9) 45.8 (±8.8) 42.2 (±8.5) 31.1 (±7.9) 17.6 (±6.0) §§§ §§§ Massachusetts 95.8 (±2.6) 91.1 (±4.2) 94.9 (±2.6) 89.6 (±3.6) 62.3 (±8.3) 48.9 (±8.6) 39.3 (±8.4) 52.8 (±8.2) 37.8 (±8.0) 21.8 (±7.0) §§§ §§§ §§§ §§§ New Hampshire 97.4 (±2.2) 91.6 (±4.1) 94.7 (±2.9) 85.6 (±4.4) 68.0 (±8.3) 57.2 (±8.6) 43.2 (±8.6) 41.4 (±8.4) 28.5 (±7.9) 17.8 (±6.7) §§§ §§§ §§§ Rhode Island 95.6 (±2.9) 93.2 (±3.6) 95.5 (±2.9) 92.0 (±3.5) 76.6 (±8.1) 68.5 (±8.7) 56.5 (±9.3) 69.3 (±8.5) 58.0 (±9.0) 43.2 (±9.0) §§§ §§§ Vermont 94.5 (±2.7) 90.9 (±4.5) 91.8 (±3.7) 79.2 (±5.3) 60.2 (±9.0) 53.5 (±9.2) 42.7 (±9.1) 41.3 (±8.8) 26.3 (±8.0) 21.7 (±7.7) §§§ §§§ §§§ HHS Region II 93.8 (±2.0) 79.1 (±3.6) 88.2 (±2.6) 86.1 (±2.6) 56.5 (±5.3) 50.2 (±5.4) 40.8 (±5.4) 36.6 (±5.1) 28.1 (±4.8) 17.5 (±4.1) §§§ §§§ New Jersey 94.9 (±3.2) 79.2 (±6.6) 85.5 (±5.3) 91.8 (±4.1) 45.8 (±9.7) 39.1 (±9.6) 31.4 (±9.2) 32.4 (±8.9) 25.7 (±8.4) 14.2 (±7.0) §§§ §§§ New York 93.3 (±2.5) 79.1 (±4.3) 89.5 (±2.9) 83.3 (±3.4) 61.7 (±6.2) 55.6 (±6.4) 45.4 (±6.6) 38.6 (±6.1) 29.3 (±5.8) 19.1 (±5.1) §§§ §§§ §§§ NY-City of New York 90.9 (±4.2) 80.6 (±6.3) 88.9 (±4.5) 83.0 (±5.2) 64.2 (±9.0) 56.1 (±9.4) 45.2 (±9.6) 46.2 (±9.6) 36.0 (±9.3) 29.6 (±9.0) §§§ NY-Rest of State 94.8 (±3.1) 78.1 (±5.9) 89.8 (±3.8) 83.6 (±4.4) 60.1 (±8.5) 55.3 (±8.7) 45.6 (±8.9) 33.8 (±7.9) 25.1 (±7.5) 12.5 (±5.9) §§§ §§§ §§§ HHS Region III 92.6 (±2.0) 80.4 (±3.4) 85.8 (±2.7) 79.7 (±3.2) 55.1 (±5.5) 48.0 (±5.4) 37.8 (±5.1) 36.5 (±5.0) 24.5 (±4.5) 14.6 (±3.7) Delaware 95.3 (±2.4) 79.8 (±6.3) 84.4 (±4.6) 81.8 (±5.1) 68.7 (±8.1) 59.4 (±8.7) 51.7 (±8.9) 37.1 (±8.5) 25.0 (±7.5) 18.1 (±6.8) §§§ §§§ §§§ Dist. of Columbia 85.9 (±8.6) 82.1 (±10.2) 83.1 (±8.3) 91.3 (±7.0) 55.6 (±14.6) 43.0 (±14.4) 30.2 (±12.3) 67.7 (±13.9) 40.2 (±14.5) 24.5 (±13.0) §§§ Maryland 93.8 (±3.9) 78.9 (±7.1) 83.2 (±6.2) 78.0 (±6.6) 50.0 (±11.5) 45.5 (±11.4) 33.4 (±10.7) 34.2 (±10.2) 23.1 (±9.0) NA §§§ §§§ §§§ Pennsylvania 93.8 (±2.8) 92.1 (±3.4) 89.9 (±3.5) 90.4 (±3.6) 59.5 (±8.1) 53.5 (±8.2) 45.9 (±8.1) 44.1 (±7.8) 26.8 (±6.9) 15.4 (±5.5) PA-Philadelphia 90.2 (±4.6) 91.8 (±4.5) 89.6 (±4.1) 92.1 (±3.8) 78.4 (±7.3) 71.2 (±8.0) 54.5 (±9.1) 55.8 (±9.7) 35.7 (±8.9) 15.8 (±6.2) §§§ §§§ PA-Rest of State 94.3 (±3.1) 92.2 (±3.8) 89.9 (±3.9) 90.2 (±4.0) 57.0 (±9.0) 51.1 (±9.1) 44.7 (±9.1) 42.7 (±8.7) 25.7 (±7.7) 15.4 (±6.2) §§§ Virginia 92.0 (±4.9) 68.0 (±9.1) 83.6 (±6.5) 64.2 (±8.5) 51.9 (±12.7) 41.4 (±12.3) 27.6 (±10.6) 26.4 (±10.6) 22.4 (±10.4) NA §§§ West Virginia 83.2 (±4.8) 59.4 (±8.1) 76.7 (±5.6) 77.3 (±5.5) 49.7 (±9.4) 43.6 (±9.2) 38.4 (±9.0) 29.4 (±8.5) 19.2 (±7.3) 15.1 (±6.6) ¶¶¶ §§§ §§§ §§§ §§§ §§§ §§§ HHS Region IV 92.2 (±1.6) 76.5 (±2.8) 82.5 (±2.3) 70.9 (±2.6) 53.0 (±4.1) 42.9 (±4.1) 33.9 (±3.9) 28.4 (±3.8) 18.6 (±3.2) 11.1 (±2.6) §§§ Alabama 93.4 (±3.2) 79.1 (±6.1) 87.3 (±4.5) 69.5 (±6.0) 54.7 (±9.2) 46.6 (±9.2) 39.6 (±9.0) 18.4 (±6.9) 10.9 (±5.2) NA Florida 93.5 (±3.8) 76.0 (±7.0) 84.8 (±5.4) 72.3 (±6.4) 49.7 (±10.2) 40.7 (±10.0) 34.3 (±9.8) 27.8 (±8.6) 16.0 (±6.6) 13.2 (±6.2) §§§ §§§ Georgia 96.4 (±3.1) 93.7 (±5.2) 82.0 (±6.6) 76.9 (±7.0) 53.7 (±10.8) 42.3 (±10.4) 33.2 (±9.5) 40.5 (±11.5) 31.0 (±10.7) 15.3 (±8.2) Kentucky 92.7 (±3.7) 66.5 (±7.7) 84.4 (±5.1) 71.2 (±6.3) 47.6 (±9.8) 38.6 (±9.5) 26.8 (±8.5) 19.0 (±7.4) 10.8 (±5.2) NA §§§ §§§ Mississippi 92.3 (±3.9) 55.7 (±8.2) 60.2 (±6.7) 50.1 (±6.9) 53.1 (±9.5) 35.6 (±9.3) 25.2 (±8.6) 13.6 (±6.6) NA NA ¶¶¶ §§§ §§§ North Carolina 87.1 (±4.7) 74.0 (±6.6) 89.4 (±4.0) 72.4 (±5.7) 59.3 (±9.5) 47.4 (±9.7) 32.8 (±9.1) 33.2 (±8.8) 24.4 (±8.0) 12.4 (±6.3) §§§ §§§ §§§ §§§ South Carolina 91.0 (±3.8) 58.6 (±8.1) 71.9 (±6.6) 68.7 (±6.6) 60.4 (±9.7) 53.0 (±10.1) 40.7 (±10.4) 22.2 (±9.0) 13.1 (±6.7) NA Tennessee 88.4 (±4.6) 79.7 (±6.5) 80.0 (±5.4) 67.8 (±6.1) 48.9 (±9.5) 39.8 (±9.4) 35.9 (±9.1) 28.9 (±8.2) 18.0 (±7.1) NA §§§ §§§ §§§ §§§ §§§ §§§ ††† ††† ††† HHS Region V 93.6 (±1.3) 83.0 (±2.4) 86.3 (±1.9) 79.9 (±2.1) 57.4 (±3.8) 46.1 (±3.8) 35.0 (±3.6) 28.3 (±3.4) 18.2 (±2.9) 12.2 (±2.5) §§§ §§§ §§§ §§§ §§§ §§§ §§§ Illinois 93.5 (±2.5) 79.9 (±5.1) 86.2 (±4.2) 79.0 (±4.5) 53.2 (±7.6) 42.6 (±7.5) 33.8 (±7.2) 34.8 (±7.5) 21.2 (±6.6) 16.5 (±6.4) §§§ IL-City of Chicago 88.8 (±5.4) 79.4 (±8.3) 89.7 (±5.2) 83.3 (±6.3) 61.8 (±12.7) 49.2 (±12.8) 38.6 (±12.1) 50.0 (±11.7) 29.1 (±10.4) 19.8 (±8.5) §§§ §§§ §§§ §§§ §§§ §§§ §§§ IL-Rest of State 94.6 (±2.8) 80.0 (±6.1) 85.4 (±5.0) 78.0 (±5.4) 51.2 (±9.0) 41.1 (±8.9) 32.6 (±8.5) 31.4 (±8.9) 19.4 (±7.8) 15.8 (±7.6) Indiana 93.7 (±3.1) 91.8 (±4.2) 90.6 (±3.3) 93.5 (±2.7) 54.1 (±8.3) 44.2 (±8.2) 34.6 (±7.7) 18.2 (±6.3) 13.5 (±5.6) 8.1 (±4.3) §§§ §§§ Michigan 94.0 (±3.4) 92.2 (±3.8) 81.0 (±5.2) 90.7 (±3.9) 66.0 (±9.1) 49.4 (±9.9) 34.5 (±9.4) 30.0 (±8.1) 16.8 (±6.7) 7.7 (±4.5) Minnesota 94.0 (±3.2) 86.3 (±6.0) 91.4 (±3.8) 66.3 (±6.2) 59.3 (±9.3) 45.8 (±9.4) 37.6 (±9.0) 22.0 (±6.7) 13.1 (±5.6) 8.6 (±4.5) §§§ §§§ §§§ Ohio 92.9 (±3.4) 66.2 (±7.4) 84.4 (±4.9) 69.2 (±6.1) 54.8 (±9.3) 47.6 (±9.4) 35.0 (±8.8) 26.5 (±8.2) 19.7 (±7.1) 14.7 (±6.4) §§§ §§§ Wisconsin 93.9 (±3.2) 93.4 (±3.7) 89.6 (±4.2) 81.4 (±4.9) 59.4 (±9.1) 47.8 (±9.4) 36.8 (±9.0) 31.7 (±8.5) 20.9 (±7.7) 13.7 (±6.7) §§§ §§§ §§§ §§§ HHS Region VI 89.0 (±2.5) 77.8 (±3.5) 84.9 (±2.6) 81.5 (±2.5) 56.2 (±5.2) 46.9 (±5.3) 38.1 (±5.2) 33.1 (±4.6) 24.2 (±4.2) 14.5 (±3.3) §§§ Arkansas 89.5 (±3.8) 59.6 (±7.6) 77.7 (±5.3) 40.4 (±6.5) 44.3 (±9.3) 35.4 (±8.9) 24.4 (±8.0) 17.7 (±7.5) NA NA §§§ Louisiana 97.4 (±2.4) 89.1 (±4.4) 87.9 (±4.5) 87.7 (±4.4) 59.8 (±9.2) 54.1 (±9.6) 42.1 (±9.8) 27.0 (±8.1) 20.5 (±7.6) 13.5 (±6.6) §§§ §§§ §§§ §§§ §§§ §§§ §§§ New Mexico 92.3 (±3.1) 72.5 (±6.3) 85.6 (±4.5) 70.9 (±5.6) 67.1 (±8.6) 56.1 (±9.2) 44.3 (±9.2) 31.4 (±7.6) 27.0 (±7.2) 19.2 (±6.6) §§§ §§§ Oklahoma 89.5 (±3.4) 67.3 (±6.2) 78.1 (±4.9) 66.2 (±5.4) 54.8 (±8.7) 46.5 (±8.7) 35.4 (±8.3) 45.2 (±7.5) 31.1 (±6.9) 17.3 (±5.7) §§§ §§§ §§§ Texas 87.3 (±3.6) 79.4 (±4.9) 86.1 (±3.6) 87.6 (±3.5) 56.2 (±7.4) 46.3 (±7.4) 38.9 (±7.4) 34.1 (±6.5) 25.2 (±5.9) 15.0 (±4.6) §§§ TX-Bexar County 87.0 (±4.4) 78.9 (±6.2) 86.6 (±4.5) 87.2 (±4.2) 54.8 (±9.1) 45.7 (±9.2) 32.5 (±8.8) 32.4 (±8.7) 19.1 (±6.9) 9.6 (±4.7) TX-City of Houston 86.8 (±5.3) 82.1 (±7.2) 86.5 (±5.6) 91.4 (±4.6) 62.0 (±10.8) 51.9 (±11.3) 33.9 (±10.6) 40.3 (±9.8) 27.8 (±8.5) 17.5 (±7.0) §§§ §§§ §§§ TX-Rest of State 87.3 (±4.1) 79.2 (±5.6) 86.0 (±4.1) 87.4 (±4.0) 55.9 (±8.6) 45.9 (±8.6) 39.8 (±8.5) 33.7 (±7.4) 25.4 (±6.8) 15.2 (±5.3) See table footnotes on next page. were primarily observed in the last quarter of the year, which Whereas eight states had 2-dose coverage >95%, 13 states and could reflect the impact of health promotion activities initiated the District of Columbia had 2-dose coverage <90%, reflecting during the summer and fall of 2013. a vulnerability to measles transmission. The high number of measles cases reported in the United In 2013, there were racial and ethnic differences for some States in 2014 (580 cases through July 18) (http://www.cdc. vaccines (MenACWY, MMR, and HPV). Compared with gov/measles/index.html) is a reminder of the importance of whites, vaccination coverage among Hispanics was higher for ≥1 achieving and maintaining high 2-dose MMR vaccination cov- MenACWY dose and each HPV dose among males and females, erage among children and adolescents throughout the country. but lower for ≥2 MMR doses. Vaccination coverage was similar 630 MMWR / July 25, 2014 / Vol. 63 / No. 29 Morbidity and Mortality Weekly Report TABLE 3. (Continued) Estimated vaccination coverage with selected vaccines and doses* among adolescents aged 13–17 years by HHS region and state/selected local area — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Females (n = 8,264) Males (n = 9,554) § ¶ †† §§ ¶¶ §§ ¶¶ ≥2 MMR ≥2 VAR ≥1 Tdap** ≥1 MenACWY ≥1 HPV ≥2 HPV ≥3 HPV*** ≥1 HPV ≥2 HPV ≥3 HPV*** Regional/State/ ††† Local area % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) §§§ §§§ §§§ HHS Region VII 89.0 (±2.5) 67.4 (±4.5) 82.4 (±2.9) 62.5 (±3.7) 49.7 (±5.6) 41.7 (±5.4) 31.7 (±4.9) 26.0 (±4.4) 16.6 (±3.5) 9.4 (±2.7) §§§ Iowa 90.2 (±4.0) 62.1 (±7.4) 79.6 (±5.0) 63.6 (±5.9) 57.0 (±8.7) 52.2 (±8.8) 41.9 (±8.8) 30.3 (±8.0) 24.0 (±7.3) 13.7 (±5.4) ¶¶¶ §§§ Kansas 86.9 (±4.6) 80.7 (±6.1) 84.6 (±4.9) 55.9 (±6.8) 39.9 (±9.9) 29.9 (±9.2) 21.0 (±8.2) 25.1 (±8.6) 19.3 (±7.8) NA Missouri 88.3 (±4.8) 58.6 (±8.6) 81.5 (±5.4) 60.7 (±7.1) 46.1 (±10.6) 38.1 (±10.1) 28.8 (±9.0) 20.5 (±7.7) NA NA §§§ §§§ §§§ Nebraska 92.3 (±3.2) 84.6 (±5.5) 86.1 (±4.7) 77.5 (±5.2) 65.1 (±9.2) 55.3 (±9.3) 41.5 (±9.1) 38.2 (±8.7) 26.4 (±7.8) 19.7 (±7.2) HHS Region VIII 91.0 (±2.1) 71.8 (±3.8) 86.1 (±2.5) 67.0 (±3.3) 52.6 (±5.0) 43.4 (±5.0) 33.1 (±4.7) 24.3 (±4.4) 16.6 (±3.8) 8.6 (±2.5) ¶¶¶ Colorado 92.4 (±3.3) 78.5 (±5.7) 87.1 (±4.4) 73.6 (±5.6) 58.2 (±8.6) 50.0 (±8.8) 39.1 (±8.7) 33.5 (±8.6) 21.7 (±7.5) 9.9 (±4.8) ¶¶¶ Montana 90.5 (±4.0) 58.6 (±8.6) 84.3 (±5.1) 51.6 (±6.6) 45.8 (±9.6) 37.9 (±9.0) 28.3 (±8.1) 23.8 (±8.1) 17.2 (±7.0) 9.4 (±4.6) §§§ §§§ §§§ §§§ North Dakota 96.1 (±1.9) 86.0 (±5.3) 95.0 (±2.9) 93.7 (±3.2) 57.5 (±9.4) 51.0 (±9.4) 41.1 (±9.1) 36.1 (±9.1) 26.6 (±8.4) 18.4 (±7.5) §§§ South Dakota 94.1 (±3.2) 50.6 (±8.4) 70.0 (±6.4) 51.7 (±6.7) 56.0 (±9.7) 52.0 (±9.7) 42.3 (±9.6) 22.1 (±7.1) 17.0 (±6.4) 8.4 (±4.2) Utah 87.5 (±4.6) 62.2 (±8.4) 86.2 (±4.9) 61.0 (±6.7) 44.3 (±9.6) 30.9 (±8.9) 20.5 (±7.8) 11.0 (±5.8) NA NA §§§ Wyoming 90.6 (±4.0) 90.1 (±4.5) 92.3 (±3.0) 63.1 (±6.2) 54.3 (±9.4) 49.5 (±9.4) 42.1 (±9.3) 16.6 (±6.0) 12.3 (±5.3) 8.4 (±4.5) §§§ §§§ HHS Region IX 90.7 (±3.4) 77.4 (±5.2) 89.7 (±3.5) 80.6 (±4.5) 66.0 (±7.5) 54.8 (±8.0) 43.3 (±8.1) 48.7 (±7.8) 32.5 (±7.7) 16.4 (±6.3) §§§ §§§ Arizona 85.4 (±4.6) 67.8 (±7.1) 84.4 (±5.0) 86.7 (±4.6) 64.1 (±8.7) 47.9 (±9.5) 37.4 (±9.2) 44.4 (±8.7) 33.5 (±8.4) 19.5 (±6.9) §§§ §§§ California 91.5 (±4.2) 79.0 (±6.5) 91.1 (±4.4) 80.9 (±5.7) 67.6 (±9.4) 57.3 (±10.0) 45.8 (±10.2) 50.9 (±9.7) 33.2 (±9.7) 16.6 (±8.0) Hawaii 90.4 (±4.5) 83.3 (±5.7) 80.2 (±5.4) 75.0 (±6.0) 52.7 (±10.1) 46.6 (±10.0) 34.4 (±9.5) 39.7 (±8.9) 29.0 (±8.1) 15.1 (±6.0) §§§ Nevada 92.8 (±3.5) 74.6 (±6.6) 88.3 (±4.1) 64.0 (±6.1) 53.8 (±9.4) 38.9 (±9.2) 27.4 (±8.3) 31.9 (±8.5) 20.4 (±7.2) 7.3 (±3.9) §§§ §§§ §§§ §§§ HHS Region X 90.0 (±2.4) 75.3 (±4.6) 84.1 (±3.0) 72.7 (±3.5) 61.0 (±5.8) 51.2 (±5.9) 40.7 (±5.9) 32.0 (±5.0) 19.3 (±4.0) 11.6 (±3.2) §§§ §§§ Alaska 92.0 (±3.7) 80.7 (±6.1) 74.3 (±5.8) 55.2 (±6.5) 52.2 (±9.4) 36.1 (±9.0) 27.1 (±8.2) 27.6 (±7.9) 17.8 (±6.9) 8.5 (±4.7) §§§ §§§ Idaho 85.2 (±5.5) 63.8 (±9.4) 74.6 (±6.6) 71.6 (±7.0) 55.0 (±10.6) 45.8 (±10.5) 31.3 (±9.6) 34.5 (±10.2) 21.6 (±8.8) NA §§§ §§§ §§§ Oregon 92.3 (±3.2) 84.3 (±4.7) 87.0 (±4.3) 65.3 (±5.8) 66.3 (±8.4) 54.9 (±8.8) 39.5 (±8.8) 35.8 (±8.1) 20.8 (±6.9) 12.2 (±5.0) §§§ §§§ Washington 89.9 (±4.0) 71.6 (±8.1) 86.2 (±5.0) 79.0 (±5.6) 60.7 (±9.7) 52.3 (±9.9) 45.3 (±9.8) 29.8 (±8.0) 18.0 (±6.3) 12.5 (±5.2) Range (83.2–97.4) (50.6–95.8) (60.2–95.5) (40.4–93.7) (39.9–76.6) (29.9–68.5) (20.5–56.5) (11.0–69.3) (10.8–58.0) (7.3–43.2) Territory Guam 84.8 (±4.6) 43.7 (±8.5) 73.8 (±5.4) 72.4 (±5.7) 69.1 (±8.2) 45.2 (±8.9) 33.6 (±8.3) 21.8 (±7.0) 8.6 (±4.2) NA U.S. Virgin Islands 92.0 (±3.0) 77.9 (±5.3) 76.4 (±5.2) 38.4 (±6.0) 33.2 (±8.5) 17.7 (±6.7) 9.5 (±4.9) 17.2 (±6.6) NA NA Abbreviations: CI = confidence interval; HHS = U.S. Department of Health and Human Services; MMR = measles, mumps, and rubella; VAR = varicella; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus; NA = not available (estimate not reported because unweighted sample size for the denominator was <30 or 95% CI half width/estimate >0.6). * Vaccination estimates for additional measures, including ≥3 doses hepatitis B, and ≥1 dose varicella vaccines are available at http://www.cdc.gov/vaccines/stats-surv/nis/default. htm#nisteen. Adolescents (N = 18,264) in the 2013 NIS-Teen were born January 11, 1995, through February 13, 2001. ≥2 doses of MMR vaccine. ≥2 doses of VAR vaccine among adolescents without a reported history of varicella. ** ≥1 dose Tdap vaccine on or after age 10 years. †† ≥1 dose of MenACWY or meningococcal-unknown type vaccine. §§ ≥1 dose of HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. For ≥1, ≥2, and ≥3 dose measures, separate percentages are reported among females only (n = 8,710) and among males only (n = 9,554). ¶¶ ≥2 doses of HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. *** ≥3 doses of HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. ††† Estimates with 95% CI half-widths >10 might not be reliable. §§§ Statistically significant (p<0.05) percentage point increase from 2012. ¶¶¶ Statistically significant (p<0.05) percentage point decrease from 2012. by poverty level except for HPV vaccination, with higher coverage However, the significantly lower rates of HPV vaccine series with ≥1, ≥2, and ≥3 HPV doses for males and ≥1 and ≥2 HPV completion in black females compared with white females war- doses for females among those living below poverty level com- rants investigation of possible differences (e.g., access to quality pared with those living at or above the poverty level. The higher care, such as access to clinicians with reminder-recall systems) coverage among some racial/ethnic minorities and those living that might limit vaccine series completion in some populations. below poverty level might be partly attributable to the continued Learning what factors are fostering achievement of increasing and effectiveness of the Vaccines for Children program (VFC), which comparatively higher HPV vaccination coverage among Hispanic provides recommended vaccines at no cost to eligible children.**** adolescents might inform strategies for the general population. The similar or higher vaccination coverage among adolescents living **** Children aged ≤18 years who are Medicaid-eligible, uninsured, or American below the poverty threshold contrasts with findings for coverage Indian/Alaska Native (as defined by the Indian Health Care Improvement Act) are eligible to receive vaccines from providers through the VFC program. Children with some early childhood vaccinations (10). Among children categorized as “underinsured” (because their health plans do not include coverage aged 19–35 months, poverty has been associated with lower for recommended vaccinations) are eligible to receive VFC vaccines if they are coverage of newer vaccines (e.g., rotavirus), and some vaccines served by a rural health clinic or federally qualified health center or under an approved deputization agreement. Additional information is available at http:// www.cdc.gov/vaccines/programs/vfc/providers/eligibility.html. MMWR / July 25, 2014 / Vol. 63 / No. 29 631 Morbidity and Mortality Weekly Report from 2012 to 2013 in only five states (Illinois, Michigan, New What is already known on this topic? Hampshire, New Mexico, and South Carolina) for ≥1 HPV The Advisory Committee on Immunization Practices (ACIP) dose and in four states (Illinois, Mississippi, New Mexico, recommends that adolescents receive 1 dose of tetanus toxoid, and South Carolina) for ≥3 HPV doses. These states have reduced diphtheria toxoid and acellular pertussis (Tdap) undertaken diverse initiatives that likely contributed to the vaccine, 2 doses of meningococcal conjugate (MenACWY ) vaccine, and 3 doses of human papillomavirus (HPV ) vaccine. significant increases in HPV vaccination coverage, including ACIP also recommends administration of these and all age- 1) developing partnerships with state chapters of the American appropriate vaccines during a single visit. During 2006–2012, Academy of Pediatrics and with the Academy of Family national vaccination coverage for ≥1 Tdap and ≥1 MenACWY Physicians to promote HPV immunization, 2) working actively increased steadily, with Tdap coverage in 2011 reaching with Immunization Coalitions and Cancer Collaboratives national target levels for adolescents. During 2007–2011, to incorporate HPV immunization into strategic plans and coverage for ≥1 HPV vaccine dose among females increased steadily, but from 2011 to 2012, there were no changes in ensuring that clinical and immunization conferences highlight coverage. Coverage for ≥1 HPV vaccine dose among males HPV vaccination topics, 3) developing an HPV Vaccine Task increased from 2011-2012. Force to discuss and facilitate HPV vaccination health promo- What is added by this report? tion activities and interventions, 4) providing peer-to-peer From 2012 to 2013, vaccination coverage among U.S. adoles- physician HPV vaccination training onsite, and 5) increasing cents increased to 86.0% for ≥1 dose of Tdap vaccine, 77.8% for provider assessment and feedback visits focused on increasing ≥1 dose of MenACWY vaccine, 57.3% for ≥1 dose of HPV vaccine vaccination coverage among adolescents. Understanding the among females, and 34.6% for ≥1 dose of HPV vaccine among extent to which vaccination programs and policies, provider males. Vaccination coverage levels continued to vary widely practices, and parental knowledge and access influence these among states. Although HPV vaccination coverage increased among both females and males, levels are still low and reflect geographic differences might help inform public health action. many missed opportunities. Five states had substantial The findings in this report are subject to at least three increases in HPV coverage from 2012 to 2013, suggesting limitations. First, the household response rates for landline greater progress is feasible. and cell phone samples were 51.1% and 23.3%, respectively. What are the implications for public health practice? Furthermore, only 59.5% of landline and 54.5% of cell phone Lower vaccination coverage for HPV compared with Tdap and completed interviews had adequate vaccine provider data. MenACWY vaccines indicates clinicians, parents, and adoles- Therefore, estimates might have been biased, even after weight- cents are missing opportunities for infection and cancer ing adjustments for nonresponse and exclusion of households prevention. Clinician recommendations strongly influence the without telephones. A total survey error model of 2011 NIS- decisions of parents to vaccinate their children; to maximize coverage, clinicians should clearly and consistently recommend Teen that included comparison with provider-reported data all ACIP-recommended vaccines, including HPV. Health care collected from a sample of National Health Interview Survey systems interventions, including use of client reminder and participants indicated coverage estimates were approximately recall systems, immunization information systems, clinician 2, 3, and 6 percentage points too high for Tdap, MenACWY, reminders, and standing orders, should be employed to and HPV (among females) vaccinations, respectively, as a result improve protection of adolescents from vaccine-preventable †††† Estimates of bias do infections and future cancers. of noncoverage and nonresponse error. not include errors in vaccination status (e.g., underascertain- ment from incomplete vaccination provider identification and that require doses during the second year of life (e.g., DTaP unknown medical record completeness) (7). Second, although and PCV) (10). response rates have been stable in recent years and weights Geographic differences in coverage continue to vary by have been adjusted to reflect the increasing prevalence of cell vaccine. Factors contributing to state or regional differences phone–only households over time, it is possible that nonre- might include different state school vaccination requirements, sponse bias might have changed over time, which could affect different stages of vaccine policy implementation, increased interpretation of comparisons across data years. Finally, some vaccine demand in response to local disease, differing parental of the state-specific and racial/ethnic-specific analyses might knowledge and attitudes toward or access to vaccination, incon- be unreliable because of small sample sizes (7). Estimates with sistent clinician adherence to and knowledge about vaccine confidence half-widths wider than 10 are less reliable, and this recommendations, and other factors. Although there was an impacts estimates for some racial and ethnic populations. For overall increase in HPV vaccination coverage among females, there was continued wide variability among states and HHS †††† Additional information available at http://www.amstat.org/meetings/ Regions. HPV coverage among females increased significantly jsm/2012/onlineprogram/abstractdetails.cfm?abstractid=304324. 632 MMWR / July 25, 2014 / Vol. 63 / No. 29 Morbidity and Mortality Weekly Report HPV coverage analyses by state and sex, small sample sizes References decrease the power to detect differences. 1. Akinsanya-Beysolow I, Advisory Committee on Immunization Practices (ACIP), ACIP Child/Adolescent Immunization Work Group. Advisory High Tdap coverage levels among adolescents aged 13–17 Committee on Immunization Practices recommended immunization years indicate that similar coverage levels are attainable for schedules for persons aged 0 through 18 years—United States, 2014. other vaccines recommended for adolescents. Improved adher- MMWR 2014;63:108–9. 2. CDC. Recommendations on the use of quadrivalent human ence of clinicians and parents to the ACIP recommendation papillomavirus vaccine in males—Advisory Committee on Immunization to administer all age-appropriate vaccines during a single visit Practices (ACIP), 2011. MMWR 2011;60:1705–8. could substantially increase lagging vaccination coverage levels. 3. CDC. General recommendations on immunization: recommendations At each encounter with a clinician, every adolescent’s immu- of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2). nization history should be reviewed to ensure complete vac- 4. US Department of Health and Human Services. Healthy People 2020. cination consistent with ACIP recommendations. Additionally, Washington, DC: US Department of Health and Human Services; 2012. clinicians should provide strong, consistent recommendations Available at http://www.healthypeople.gov/2020/topicsobjectives2020/ objectiveslist.aspx?topicId-23. for all ACIP-recommended vaccines. HPV vaccine should be 5. Community Preventive Services Task Force. Increasing appropriate recommended with the same emphasis and at the same time vaccination. Atlanta, GA: Community Preventive Services Task Force; 2014. as the other vaccines for adolescents. Recommended strategies Available at http://www.thecommunityguide.org/vaccines/index.html. 6. CDC. Updated recommendations for use of meningococcal conjugate to improve vaccination coverage include use of combinations vaccines—Advisory Committee on Immunization Practices (ACIP), of strategies such as patient reminder and recall systems, 2010. MMWR 2011;60:72–6. standing orders, and use of immunization information sys- 7. CDC. National and state vaccination coverage among adolescents aged 13–17 years—United States, 2012. MMWR 2013;62:685–93. tems (5). Coverage levels should continue to be monitored 8. Holmon DM, Bernard V, Roland KB, Watson M, Liddon N, Stokley to describe coverage disparities, to use estimates to identify S. Barriers to human papillomavirus vaccination among U.S. adolescents: target populations for interventions to increase coverage, and a systematic review of the literature. JAMA Pediatr 2014;168:76–82. to inform development of additional policies that will sup- 9. Stokley S, Jeyarajah J, Yankey D, et al. Human papillomavirus vaccination coverage among adolescents, 2007–2013, and postlicensure vaccine safety port further efforts to reduce vaccine-preventable diseases, monitoring, 2006–2014—United States. MMWR 2014;63:620–4. including cancers. 10. CDC. National, state, and local area vaccination coverage among children aged 19–35 months—United States, 2012. MMWR 2013;62:733–40. Immunization Services Division, National Center for Immunization and Respiratory Diseases; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases; Division of Sexually Transmitted Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (Corresponding contributor: Laurie D. Elam-Evans, [email protected], 404-718-4838) MMWR / July 25, 2014 / Vol. 63 / No. 29 633 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png MMWR. Morbidity and Mortality Weekly Report Pubmed Central

National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2013

Elam-Evans, Laurie D.; Yankey, David; Jeyarajah, Jenny; Singleton, James A.; Curtis, C. Robinette; MacNeil, Jessica; Hariri, Susan
MMWR. Morbidity and Mortality Weekly Report , Volume 63 (29) – Jul 25, 2014
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Abstract

Morbidity and Mortality Weekly Report National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2013 1 1 1 1 1 Laurie D. Elam-Evans, PhD , David Yankey, MS , Jenny Jeyarajah, MS , James A. Singleton, PhD , C. Robinette Curtis, MD , 2 3 Jessica MacNeil, MPH , Susan Hariri, PhD (Author affiliations at end of text) The Advisory Committee on Immunization Practices state met the target for ≥3 HPV doses. Use of patient reminder (ACIP) recommends that adolescents routinely receive 1 dose and recall systems, immunization information systems, cover- of tetanus toxoid, reduced diphtheria toxoid, and acellular age assessment and feedback to clinicians, clinician reminders, pertussis (Tdap) vaccine, 2 doses of meningococcal conjugate standing orders, and other interventions can help make use (MenACWY) vaccine, and 3 doses of human papillomavirus of every health care visit to ensure that adolescents are fully (HPV) vaccine (1,2).* ACIP also recommends administration protected from vaccine-preventable infections and cancers (5), of “catch-up” vaccinations, such as measles, mumps, and especially when such interventions are coupled with clinicians’ rubella (MMR), hepatitis B, and varicella, and, for all persons vaccination recommendations. aged ≥6 months, an annual influenza vaccination (1). ACIP Vaccination coverage was assessed using 2013 NIS-Teen data recommends administration of all age-appropriate vaccines for adolescents aged 13–17 years in the 50 states, the District during a single visit (3). To assess vaccination coverage among of Columbia, selected local areas,** Guam, and the U.S. Virgin adolescents aged 13–17 years, CDC analyzed data from the Islands, using a random-digit–dialed sample of landline and § †† 2013 National Immunization Survey-Teen (NIS-Teen). This cell phones. Telephone interviews were conducted with the report summarizes the results of that analysis, which show that parent or guardian of age-eligible adolescents to obtain infor- from 2012 to 2013, coverage increased for each of the vaccines mation about the adolescent’s demographic characteristics and §§ routinely recommended for adolescents: from 84.6% to 86.0% to request vaccination provider contact information. After for ≥1 Tdap dose; from 74.0% to 77.8% for ≥1 MenACWY receiving a respondent’s consent, a questionnaire was mailed dose; from 53.8% to 57.3% for ≥1 HPV dose among females, to each vaccination provider to obtain provider-confirmed and from 20.8% to 34.6% for ≥1 HPV dose among males. immunization information. In 2013, national estimates were Coverage varied by state and local jurisdictions and by U.S. based on responses for 18,264 adolescents (8,710 females and Department of Health and Human Services (HHS) region. Healthy People 2020 vaccination targets for adolescents aged HP2020 objectives and targets were established for females only in 2010 (4), before ACIP’s 2011 recommendation for routine use of the quadrivalent HPV 13–15 years (4) were reached in 42 states for ≥1 Tdap dose, vaccine among males aged 11–12 years (2). In April 2014, the federal HP2020 18 for ≥1 MenACWY dose, and 11 for ≥2 varicella doses. No work group approved a new HP2020 objective to reach an 80% vaccination target with 3 doses of HPV vaccine among adolescent males aged 13–15 years (Office of Policy, Office of the Director, National Center for Immunization * Adolescents who receive their first MenACWY vaccine dose as routinely and Respiratory Diseases, CDC, unpublished data, April 2014). recommended at age 11–12 years should receive a second dose at 16 years. ** Local areas that received Federal Section 317 immunization funds were Adolescents who receive their first dose at ages 13–15 years should receive a sampled separately: Chicago, Illinois; New York, New York; Philadelphia second dose at age 16–18 years, with a minimum interval of ≥8 weeks between County, Pennsylvania; Bexar County, Texas; and Houston, Texas. †† doses. Adolescents who receive a MenACWY vaccine dose at age ≥16 years do All identified cell phone households were eligible for interview. Sampling not need a second dose. weights adjusted to correct for dual-frame (landline and cell phone) sampling, Catch-up vaccination is recommended for some vaccines routinely nonresponse, noncoverage, and overlapping samples of mixed telephone users. recommended in childhood. MMR vaccine is recommended for any adolescents A description of NIS-Teen dual-frame survey methodology and its effect on who have not had 2 doses of MMR vaccine. Catch-up vaccination for varicella reported vaccination estimates is available at http://www.cdc.gov/vaccines/ is recommended for persons aged 7–18 years without evidence of immunity stats-surv/nis/dual-frame-sampling-082812.htm. §§ (MMWR 2007;56 [No. RR-4]). Adolescents should have received 2 doses of The Council of American Survey Research Organizations (CASRO) response varicella vaccine. Catch up vaccination for hepatitis B is recommended for any rate for the landline and cell phone samples were 51.1% and 23.3%, unvaccinated persons, and they should complete a 3-dose series. However, a respectively. For completed interviews, 6,039 by landline (59.5%) and 12,225 2-dose series (doses separated by at least 4 months) of adult formulation by cell phone (54.5%) had adequate provider data. Overall, 33% of completed Recombivax HB is licensed for use in children aged 11–15 years (1). interviews with adequate provider data were from landlines, and 67% were Eligible participants were born during January 1995–February 2001. Except from cell phones. For USVI, the landline and cell phone sample CASRO rate as noted, coverage for ≥1 and ≥2 varicella doses were obtained among persons was 60.6% and 31.5%, respectively. For Guam, landline and cell phone sample with no history of varicella disease. HPV vaccination coverage represents receipt CASRO was 45.6% and 21.0%, respectively. The CASRO response rate is of any HPV vaccine and does not distinguish between bivalent or quadrivalent the product of three other rates: 1) the resolution rate (the proportion of vaccines. Some adolescents, both males and females, might have received more telephone numbers that can be identified as either for business or residence), than the 3 recommended HPV doses. Influenza vaccination coverage estimates 2) the screening rate (the proportion of qualified households that complete are not included in this report but are available online at http://www.cdc.gov/ the screening process), and 3) the cooperation rate (the proportion of contacted flu/fluvaxview/index.htm. eligible households for which a completed interview is obtained). MMWR / July 25, 2014 / Vol. 63 / No. 29 625 Morbidity and Mortality Weekly Report ¶¶ 9,554 males). Details of NIS-Teen methodology, including National Vaccination Coverage methods for synthesizing provider-reported immunization During 2006–2013, NIS-Teen data show that coverage histories and weighting, have been described previously.*** trends differed substantially for Tdap, MenACWY, and HPV NIS-Teen data from 2006–2013 were used in this report vaccination (Figure). Coverage estimates for ≥1 Tdap dose and to describe vaccination coverage over time. Weighted linear ≥1 MenACWY dose increased significantly each year from ††† regression was used to assess coverage trends for vaccines 2006 to 2013, with average increases of 10.4 percentage points recommended routinely for adolescents. T-tests were used to (95% confidence interval [CI] = 7.8–13.1) for Tdap and 8.9 assess vaccination coverage differences by survey year (2013 percentage points (CI = 6.5–11.3) for MenACWY. Coverage compared with 2012), age, sex, race/ethnicity, and poverty for ≥1 HPV dose increased an average of 4.5 percentage points status for all vaccines included in this report. Results were (CI = 2.7–6.3) annually from 2007 to 2013 for females, and considered statistically significant at p<0.05. by 9.9 percentage points (CI = 4.8–15.0) from 2010 to 2013 for males. In 2013, Tdap and MenACWY coverage estimates were 86.0% and 77.8%, respectively (Table 1). From 2012 ¶¶ Adolescents from the U.S. Virgin Islands (156 females and 176 males) and from Guam (164 females and 199 males) were excluded from the national estimates. to 2013, coverage with ≥1, ≥2, and ≥3 HPV doses increased *** Additional information available at ftp://ftp.cdc.gov/pub/health_statistics/ for both sexes. Coverage with ≥1 HPV dose in 2013 was nchs/dataset_documentation/nis/nisteenpuf12_dug.pdf. ††† 57.3% for females and 34.6% for males. No statistically sig- Annual estimates of vaccination coverage were regressed on survey year via a weighted linear regression, with regression weights calculated using the nificant changes occurred from 2012 to 2013 in coverage for inverse of the estimated variance of the vaccination coverage point estimate. ≥2 doses of MMR vaccine or ≥3 doses of hepatitis B vaccine. However, coverage for ≥2 doses of varicella vaccine increased FIGURE. Estimated vaccination coverage with selected vaccines and doses among adolescents aged 13–17 years, by survey year — National Immunization Survey-Teen, United States, 2006–2013 Tdap* MenACWY ≥1 HPV (females) ≥3 HPV (females) ≥1 HPV (males) ≥3 HPV (males) 2006 2007 2008 2009 2010 2011 2012 2013 Survey year Abbreviations: Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus. * ≥1 dose Tdap vaccine on or after age 10 years. ≥1 dose MenACWY vaccine. HPV vaccine, either bivalent or quadrivalent, among females. The Advisory Committee on Immunization Practices (ACIP) recommends either bivalent or quadrivalent vaccine for females. HPV vaccine, either bivalent or quadrivalent, among males. ACIP recommends the quadrivalent vaccine for males; however, some males might have received bivalent vaccine. 626 MMWR / July 25, 2014 / Vol. 63 / No. 29 % vaccinated Morbidity and Mortality Weekly Report TABLE 1. Estimated vaccination coverage with selected vaccines among adolescents aged 13–17 years,* by age at interview — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Age at interview (yrs) Total 13 14 15 16 17 2013 2012 (n = 3,735) (n = 3,841) (n = 3,645 ) (n = 3,783 ) (n = 3,260 ) (N = 18,264 ) (N = 19,199 ) Vaccine % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) § ¶ Tdap ≥ 1 dose 87.2 (±1.9) 87.0 (±2.1) 88.4 (±1.7) 84.3 (±2.1) 83.0 (±2.7) 86.0 (±0.9)** 84.6 (±0.9) †† ¶ MenACWY ≥1 dose 76.1 (±2.4) 78.2 (±2.3) 80.0 (±2.3) 77.8 (±2.5) 76.7 (±2.9) 77.8 (±1.1)** 74.0 (±1.1) §§ HPV vaccination Females ¶ ¶ ¶ ≥1 dose 50.6 (±4.1) 55.1 (±4.2) 58.8 (±4.3) 60.0 (±4.5) 62.3 (±4.5) 57.3 (±1.9)** 53.8 (±1.9) ¶ ¶ ¶ ≥2 dose 39.2 (±4.2) 43.3 (±4.2) 48.7 (±4.5) 51.1 (±4.6) 56.8 (±4.5) 47.7 (±2.0)** 43.4 (±1.9) ¶ ¶ ¶ ¶ ≥3 doses 25.8 (±3.8) 32.1 (±3.9) 39.4 (±4.6) 43.1 (±4.5) 48.2 (±4.5) 37.6 (±1.9)** 33.4 (±1.7) Males ≥1 dose 33.5 (±4.5) 35.1 (±4.4) 36.2 (±4.1) 35.9 (±4.0) 32.1 (±4.1) 34.6 (±1.9)** 20.8 (±1.5) ≥2 dose 23.4 (±4.3) 24.3 (±4.0) 23.8 (±3.8) 23.2 (±3.7) 22.9 (±3.5) 23.5 (±1.7)** 12.7 (±1.3) ≥3 doses 11.7 (±2.7) 13.6 (±3.3) 15.3 (±3.5) 13.7 (±3.1) 15.1 (±3.0) 13.9 (±1.4)** 6.8 (±1.0) §§ HPV 3-dose series ¶¶ completion ¶ ¶ ¶ Females 56.1 (±6.7) 64.7 (±5.7) 72.1 (±5.0) 75.9 (±5.6) 79.5 (±4.6) 70.4 (±2.5)** 66.7 (±2.6) Males 41.6 (±9.4) 47.1 (±9.3) 51.0 (±8.7) 48.8 (±8.2) 53.4 (±8.5) 48.3 (±4.0) 45.1 (±5.0) MMR*** ≥2 doses 92.6 (±1.4) 93.1 (±1.4) 91.4 (±2.1) 92.0 (±1.6) 89.7 (±2.3) 91.8 (±0.8) 91.4 (±0.8) Hepatitis B ≥3 doses 94.7 (±1.3) 94.0 (±1.3) 92.5 (±1.9) 93.1 (±1.5) 91.4 (±2.2) 93.2 (±0.7) 92.8 (±0.7) Varicella ††† ¶ ¶ ¶ ¶ History of varicella 15.6 (±2.1) 19.5 (±2.4) 25.1 (±2.5) 30.6 (±2.8) 37.1 (±3.0) 25.4 (±1.2)** 30.6 (±1.2) Among adolescents with no history of varicella ¶ ¶ ¶ ¶ ≥1 dose vaccine 97.4 (±0.8) 95.4 (±1.6) 94.6 (±2.0) 94.0 (±1.9) 91.9 (±3.3) 94.9 (±0.9) 94.7 (±0.8) ¶ ¶ ¶ ≥2 doses vaccine 83.1 (±2.2) 80.2 (±2.5) 78.7 (±3.0) 76.6 (±3.1) 71.6 (±4.0) 78.5 (±1.3)** 74.9 (±1.4) History of varicella or 85.7 (±1.9) 84.1 (±2.1) 84.0 (±2.3) 83.7 (±2.3) 82.2 (±2.8) 84.0 (±1.0) 82.6 (±1.0) received ≥2 doses varicella vaccination Abbreviations: CI = confidence interval; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus; MMR = measles, mumps, and rubella. * Adolescents (N = 18,264) in the 2013 NIS-Teen were born January 11, 1995, through February 13, 2001. Estimates for overall NIS-Teen data for 2012 are provided as a comparison with overall 2013 NIS-Teen data. Includes percentages receiving Tdap vaccine at or after age 10 years. Statistically significant difference (p<0.05) in estimated vaccination coverage by age: reference group was adolescents aged 13 years. ** Statistically significant difference (p<0.05) compared with 2012 NIS-Teen overall estimates. †† Includes percentages receiving MenACWY or meningococcal-unknown type vaccine. §§ HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. Percentage reported among females (n = 8,710) and males (n = 9,554). Some adolescents might have received more than the recommended 3 doses of HPV vaccine. ¶¶ The completion rate for the 3-dose HPV vaccination series represents the percentage of adolescents who received ≥3 doses among those who had ≥1 HPV vaccine dose with at least 24 weeks between the first dose and the interview date. The calculation was limited to 4,611 females and 2,580 males who met the criteria of having received ≥1 HPV vaccine dose and having at least 24 weeks between the first dose and the interview date. *** ≥2 doses of MMR vaccine. ††† By parent/guardian report or provider records. from 74.9% to 78.5% among adolescents with no history of Vaccination Coverage by Selected Characteristics disease (Table 1). In 2013, among females, ≥1 HPV dose coverage was signifi- Coverage with the second MenACWY dose was calculated cantly higher among adolescents aged 15–17 years compared as the proportion of adolescents aged 17 years on date of with younger adolescents (Table 1). However, ≥1 HPV dose interview who received a second MenACWY dose on or after coverage for males did not vary by age. In 2013, as found their 16th birthday, among those who had received a first previously, most vaccination coverage rates were similar by dose before their 16th birthday (only second doses received sex; however, females had greater vaccination coverage than on or after their 16th birthday and at least 8 weeks after the males for ≥1, ≥2, and ≥3 HPV doses and 3-dose HPV series §§§ first dose were counted). All of these adolescents were aged 16 completion (Table 1). Also, females had significantly higher years after the MenACWY second dose was recommended by §§§ ACIP in October 2010 (n = 2,310) (6). The MenACWY 2-dose The completion rate for 3-dose HPV vaccination series represents the percentage of adolescents who received ≥3 doses among those who had ≥1 completion rate was 29.6% (CI = 26.4%–33.0%). HPV dose and ≥24 weeks between the first dose and the interview date. MMWR / July 25, 2014 / Vol. 63 / No. 29 627 Morbidity and Mortality Weekly Report vaccination coverage than males for ≥2 varicella doses (80.0% coverage was higher among Hispanic compared with white [CI = 78.1%–81.7%] versus 77.2% [CI = 75.2%–79.0%]). adolescents. Among males, ≥1, ≥2, and ≥3 HPV dose coverage In 2013, there were no racial or ethnic differences in vac- was higher among black and Hispanic adolescents compared cination coverage for ≥1 Tdap, ≥3 hepatitis B, or ≥2 varicella with white adolescents. Black adolescent females had lower (Table 2). However, ≥1 MenACWY dose coverage was higher HPV 3-dose series completion compared with white adolescent among Hispanic and Asian adolescents compared with white females and, in contrast to findings in 2012, series comple- adolescents. Among females, ≥1, ≥2, and ≥3 HPV dose tion among Hispanic females was similar to coverage among † § TABLE 2. Estimated vaccination coverage among adolescents aged 13–17 years,* by race/ethnicity, poverty level, and selected vaccines and doses — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Race/Ethnicity Poverty status American Indian/ White, non- Black, Alaska Native, Asian, Below poverty At or above Hispanic non-Hispanic Hispanic non-Hispanic non-Hispanic Multiracial level poverty level (n = 12,064) (n = 1,647 ) (n = 2,741 ) (n = 284) (n = 561 ) (n = 886 ) (n = 3,078 ) (n = 14,754) Vaccines % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Tdap** ≥1 dose 85.9 (±1.1) 84.1 (±3.0) 87.1 (±2.4) 85.3 (±7.2) 89.7 (±3.6) 85.4 (±4.9) 85.2 (±2.3) 86.4 (±1.0) †† §§ §§ MenACWY ≥1 dose 75.6 (±1.3) 77.0 (±3.3) 83.4 (±2.8) 71.7 (±11.1) 83.8 (±7.1) 76.3 (±5.1) 78.4 (±2.6) 77.5 (±1.2) ¶¶ HPV vaccination Females §§ §§ §§ ≥1 dose 53.1 (±2.3) 55.8 (±5.2) 67.5 (±5.0) 73.3 (±14.7) 57.0 (±11.4) 57.6 (±9.3) 66.8 (±4.3) 54.6 (±2.2) §§ §§ ≥2 dose 44.0 (±2.2) 45.6 (±5.2) 57.7 (±5.4) 57.3 (±15.2) 47.2 (±11.2) 46.2 (±9.5) 55.2 (±4.6) 45.3 (±2.2) §§ ≥3 doses 34.9 (±2.1) 34.2 (±4.8) 44.8 (±5.6) 43.2 (±14.2) 40.4 (±11.0) 40.3 (±9.3) 41.5 (±4.6) 36.4 (±2.1) Males §§ §§ §§ §§ ≥1 dose 26.7 (±1.9) 42.2 (±5.5) 49.6 (±5.2) 38.6 (±14.0) 26.3 (±8.9) 34.5 (±7.3) 46.7 (±4.5) 30.8 (±2.0) §§ §§ §§ ≥2 dose 18.5 (±1.7) 27.5 (±4.8) 34.5 (±5.3) 24.8 (±11.4) 19.5 (±8.0) 19.1 (±5.2) 28.7 (±4.0) 22.0 (±1.9) §§ §§ §§ ≥3 doses 11.1 (±1.3) 15.7 (±3.8) 20.3 (±4.5) NA NA 9.1 (±4.5) 12.5 (±4.2) 16.7 (±3.0) 13.0 (±1.6) ¶¶ HPV 3-dose series completion*** §§ Females 71.8 (±2.9) 63.7 (±7.3) 69.5 (±6.1) 60.1 (±16.9) 77.2 (±12.1) 75.1 (±13.8) 66.2 (±5.7) 71.9 (±2.8) Males 51.1 (±4.7) 44.8 (±8.8) 47.4 (±9.0) 48.4 (±20.0) 40.0 (±18.8) 49.3 (±13.9) 44.3 (±7.2) 50.4 (±4.8) ††† §§ MMR ≥2 doses 92.8 (±0.8) 91.1 (±2.4) 90.2 (±2.3) 93.5 (±5.2) 90.8 (±6.0) 89.8 (±3.7) 91.7 (±1.7) 91.8 (±0.9) Hepatitis B ≥3 doses 93.8 (±0.8) 93.2 (±2.1) 92.8 (±2.0) 93.4 (±5.3) 87.8 (±6.6) 91.7 (±3.1) 93.2 (±1.6) 93.1 (±0.9) Varicella §§§ §§ §§ §§ History of varicella 26.8 (±1.4) 22.6 (±3.5) 24.6 (±3.0) 36.6 (±10.6) 24.2 (±6.7) 18.5 (±3.9) 29.0 (±3.0) 24.0 (±1.2) Among adolescents with no history of varicella ≥1 dose vaccine 95.3 (±0.8) 94.3 (±2.6) 94.5 (±2.5) 95.7 (±3.7) 94.3 (±6.7) 94.4 (±3.0) 94.7 (±1.9) 95.2 (±1.0) ≥2 dose vaccine 77.7 (±1.5) 77.9 (±3.6) 80.3 (±3.5) 78.7 (±9.8) 85.2 (±8.1) 76.7 (±6.4) 77.3 (±3.0) 79.0 (±1.5) History of varicella or 83.7 (±1.1) 82.9 (±3.0) 85.2 (±2.7) 86.5 (±6.4) 88.8 (±6.3) 81.0 (±5.4) 83.8 (±2.3) 84.0 (±1.1) received ≥2 doses varicella vaccination Abbreviations: CI = confidence interval; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus; NA = not available (estimate not reported because unweighted sample size for the denominator was <30 or 95% CI half width/estimate >0.6); MMR = measles, mumps, and rubella. * Adolescents (N = 18,264) in the 2013 NIS-Teen were born January 11, 1995, through February 13, 2001. Adolescent’s race/ethnicity was reported by parent or guardian. Adolescents identified in this report as white, black, Asian, American Indian/Alaska Native or multiracial were reported by the parent or guardian as non-Hispanic. Adolescents identified as multiracial had more than one race category selected. Adolescents identified as Hispanic might be of any race. Native Hawaiian or other Pacific Islanders were not included in the table because of small sample sizes. 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 http://www.census.gov/hhes/ www/poverty.html. Poverty status was unknown for 432 adolescents. Estimates with 95% CI half-widths >10 might not be reliable. ** Includes percentages receiving Tdap vaccine at or after age 10 years. †† Includes percentages receiving MenACWY and meningococcal-unknown type vaccine. §§ Statistically significant difference (p<0.05) in estimated vaccination coverage by race/ethnicity or poverty level; referent groups were non-Hispanic white adolescents and adolescents living at or above poverty level, respectively. ¶¶ HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. Percentage reported among females (n = 8,710) and males (n = 9,554). Some adolescents might have received more than the 3 recommended HPV vaccine doses. *** The completion rate for the 3-dose HPV vaccination series represents the percentage of adolescents who received ≥3 doses among those who had ≥1 HPV vaccine dose with at least 24 weeks between the first dose and the interview date. The calculation was limited to 4,611 females and 2,580 males who met the criteria of having received ≥1 HPV vaccine dose and having ≥24 weeks between the first dose and the interview date. ††† Includes ≥2 doses of MMR vaccine. §§§ By parent/guardian report or provider records. 628 MMWR / July 25, 2014 / Vol. 63 / No. 29 Morbidity and Mortality Weekly Report white adolescent females. There were no statistically significant (CI = 30.3%–35.2%) for ≥3 HPV doses (among females), and racial/ethnic differences among males for HPV 3-dose series 80.7% (79.2%–82.1%) for ≥2 varicella doses. From 2012 to completion. In 2013, vaccination coverage did not vary by 2013, vaccination coverage for these national targets increased ¶¶¶ poverty level for ≥1 Tdap, ≥1 MenACWY, ≥2 MMR, ≥ 3 by 2.2–4.6 percentage points. The number of states meeting hepatitis B, ≥2 varicella, or HPV 3-dose series completion (for or exceeding the target was 42 for ≥1 Tdap dose (up from 36 males or females) (Table 2). However, those living below the in 2012), 18 for ≥1 MenACWY dose (up from 12 in 2012), poverty level had higher ≥1, ≥2, and ≥3 HPV dose coverage 11 for ≥2 varicella doses (up from 9 in 2012), and for ≥3 HPV (for males) and ≥1 and ≥2 HPV dose coverage (for females), doses among females, none. compared with their counterparts living at or above the poverty Discussion level. These findings in 2013 data that females had no differ- ence in 3-dose HPV completion by poverty status were not From 2012 to 2013, coverage for adolescents aged 13–17 observed in 2012 (7). years increased for all vaccinations routinely recommended for adolescents, with increases ranging from 1.4 percentage points State and Regional Vaccination Coverage for ≥1 Tdap dose to 13.8 percentage points for ≥1 HPV dose in males. Nationally, the Healthy People 2020 vaccination cov- In 2013, there was wide variation among states in cover- erage target for adolescents aged 13–15 years was reached for age (Table 3). Coverage for ≥1 Tdap ranged from 60.2% Tdap (87.5%) for the third survey year, and progress continues (Mississippi) to 95.5% (Rhode Island), whereas coverage for MenACWY (78.1%) and varicella (80.7%). These high estimates for ≥1 MenACWY ranged from 40.4% (Arkansas) vaccination coverage levels confirm that established targets of to 93.7% (North Dakota). Among females, coverage for ≥1 80%–90% are achievable for adolescents for vaccination and HPV doses ranged from 39.9% (Kansas) to 76.6% (Rhode vaccination series, just as they are for young children. However, Island) and for ≥3 HPV doses ranged from 20.5% (Utah) to coverage for ≥3 HPV doses among females aged 13–15 years 56.5% (Rhode Island). For males, coverage for ≥1 HPV doses in 2013 was 32.7%, and trends measured by 2013 and earlier ranged from 11.0% (Utah) to 69.3% (Rhode Island) and for NIS-Teen data demonstrate that the 80% Healthy People 2020 ≥3 HPV doses ranged from 7.3% (Nevada) to 43.2% (Rhode target will be difficult to achieve without changes in clinical Island). Coverage for ≥2 MMR doses ranged from 83.2% practices, leaving adolescents vulnerable to develop the cancers (West Virginia) to 97.4% (New Hampshire and Louisiana). that safe, effective HPV vaccines can prevent. Accelerating Coverage for ≥2 varicella doses ranged from 50.6% (South progress in HPV vaccination will require the collaboration of Dakota) to 95.8% (Connecticut). numerous stakeholders (e.g., clinicians, parents, adolescents, Coverage with ≥1 HPV doses in females increased from 2012 and public health professionals) to overcome barriers to use of to 2013 in five states (Illinois, Michigan, New Hampshire, New HPV vaccines (8). A variety of factors, including knowledge, Mexico, and South Carolina), with percentage point increases attitudes, and behaviors among clinicians and parents likely ranging from 12.0 (Illinois) to 18.5 (South Carolina). HPV contribute to lower HPV vaccination initiation compared coverage with ≥1 doses in females also increased by 6.0 percent- with Tdap and MenACWY vaccinations. Addressing barri- age points (CI = 0.1–12.0) in HHS Region IV (southeastern ers to HPV vaccination at the recommended ages of 11–12 states) and by 7.8 percentage points (CI = 2.1–13.4) in HHS years could reduce missed opportunities to administer all Region V (north central states) (Table 3). recommended adolescent vaccines during the same clinical encounter. Another analysis of 2013 NIS-Teen data indicates Healthy People 2020 Targets that for adolescent females born in 2000, coverage with at least The Healthy People 2020 national targets for vaccination 1 dose of HPV vaccine before age 13 years could have reached coverage among adolescents aged 13–15 years are 80.0% 91.3% if opportunities to administer HPV vaccine when other for ≥1 Tdap dose, ≥1 MenACWY dose, and ≥3 HPV doses vaccines were given had not been missed (9). (among females) and 90.0% for ≥2 varicella doses (4). Among Although HPV vaccination of adolescent females increased adolescents aged 13–15 years, vaccination coverage in 2013 by only 3.5 percentage points from 2012 to 2013, this increase was 87.5% (CI = 86.4%–88.6%) for ≥1 Tdap dose, 78.1% was significantly greater than that observed from 2011 to 2012, (CI = 76.7%–79.4%) for ≥1 MenACWY dose, 32.7% when first dose HPV coverage among adolescent females stag- ¶¶¶ nated. Whether increased health promotion activities aimed Adolescents were classified as below the federal poverty level if their family’s total income was less than the federal poverty level specified for their family at clinicians (e.g., http://www.cdc.gov/vaccines/youarethekey) size and number of children aged <18 years. All others were classified as at or and parents initiated during 2013 account for the modest above the poverty level. Poverty status was unknown for 432 adolescents. Additional information available at http://www.census.gov/hhs/www/poverty. increase is not known. Vaccination coverage increases in 2013 MMWR / July 25, 2014 / Vol. 63 / No. 29 629 Morbidity and Mortality Weekly Report TABLE 3. Estimated vaccination coverage with selected vaccines and doses* among adolescents aged 13–17 years by HHS region and state/ selected local area — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Females (n = 8,264) Males (n = 9,554) § ¶ †† §§ ¶¶ §§ ¶¶ ≥2 MMR ≥2 VAR ≥1 Tdap** ≥1 MenACWY ≥1 HPV ≥2 HPV ≥3 HPV*** ≥1 HPV ≥2 HPV ≥3 HPV*** Regional/State/ ††† Local area % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) §§§ §§§ §§§ §§§ §§§ §§§ §§§ §§§ §§§ United Sates overall 91.8 (±0.8) 78.5 (±1.3) 86.0 (±0.9) 77.8 (±1.1) 57.3 (±1.9) 47.7 (±2.0) 37.6 (±1.9) 34.6 (±1.9) 23.5 (±1.7) 13.9 (±1.4) §§§ §§§ §§§ HHS Region I 95.7 (±1.4) 90.9 (±2.3) 92.7 (±1.7) 87.7 (±2.1) 61.9 (±4.6) 51.8 (±4.8) 41.8 (±4.7) 51.4 (±4.6) 36.9 (±4.5) 23.0 (±3.9) §§§ §§§ §§§ Connecticut 97.3 (±2.4) 95.8 (±3.2) 90.8 (±4.3) 90.6 (±4.2) 56.0 (±9.2) 49.0 (±9.3) 40.1 (±9.1) 52.3 (±9.2) 36.4 (±8.9) 23.4 (±7.9) ¶¶¶ §§§ §§§ Maine 88.8 (±4.4) 71.0 (±7.2) 83.0 (±4.7) 71.2 (±5.6) 60.2 (±8.8) 55.4 (±8.9) 45.8 (±8.8) 42.2 (±8.5) 31.1 (±7.9) 17.6 (±6.0) §§§ §§§ Massachusetts 95.8 (±2.6) 91.1 (±4.2) 94.9 (±2.6) 89.6 (±3.6) 62.3 (±8.3) 48.9 (±8.6) 39.3 (±8.4) 52.8 (±8.2) 37.8 (±8.0) 21.8 (±7.0) §§§ §§§ §§§ §§§ New Hampshire 97.4 (±2.2) 91.6 (±4.1) 94.7 (±2.9) 85.6 (±4.4) 68.0 (±8.3) 57.2 (±8.6) 43.2 (±8.6) 41.4 (±8.4) 28.5 (±7.9) 17.8 (±6.7) §§§ §§§ §§§ Rhode Island 95.6 (±2.9) 93.2 (±3.6) 95.5 (±2.9) 92.0 (±3.5) 76.6 (±8.1) 68.5 (±8.7) 56.5 (±9.3) 69.3 (±8.5) 58.0 (±9.0) 43.2 (±9.0) §§§ §§§ Vermont 94.5 (±2.7) 90.9 (±4.5) 91.8 (±3.7) 79.2 (±5.3) 60.2 (±9.0) 53.5 (±9.2) 42.7 (±9.1) 41.3 (±8.8) 26.3 (±8.0) 21.7 (±7.7) §§§ §§§ §§§ HHS Region II 93.8 (±2.0) 79.1 (±3.6) 88.2 (±2.6) 86.1 (±2.6) 56.5 (±5.3) 50.2 (±5.4) 40.8 (±5.4) 36.6 (±5.1) 28.1 (±4.8) 17.5 (±4.1) §§§ §§§ New Jersey 94.9 (±3.2) 79.2 (±6.6) 85.5 (±5.3) 91.8 (±4.1) 45.8 (±9.7) 39.1 (±9.6) 31.4 (±9.2) 32.4 (±8.9) 25.7 (±8.4) 14.2 (±7.0) §§§ §§§ New York 93.3 (±2.5) 79.1 (±4.3) 89.5 (±2.9) 83.3 (±3.4) 61.7 (±6.2) 55.6 (±6.4) 45.4 (±6.6) 38.6 (±6.1) 29.3 (±5.8) 19.1 (±5.1) §§§ §§§ §§§ NY-City of New York 90.9 (±4.2) 80.6 (±6.3) 88.9 (±4.5) 83.0 (±5.2) 64.2 (±9.0) 56.1 (±9.4) 45.2 (±9.6) 46.2 (±9.6) 36.0 (±9.3) 29.6 (±9.0) §§§ NY-Rest of State 94.8 (±3.1) 78.1 (±5.9) 89.8 (±3.8) 83.6 (±4.4) 60.1 (±8.5) 55.3 (±8.7) 45.6 (±8.9) 33.8 (±7.9) 25.1 (±7.5) 12.5 (±5.9) §§§ §§§ §§§ HHS Region III 92.6 (±2.0) 80.4 (±3.4) 85.8 (±2.7) 79.7 (±3.2) 55.1 (±5.5) 48.0 (±5.4) 37.8 (±5.1) 36.5 (±5.0) 24.5 (±4.5) 14.6 (±3.7) Delaware 95.3 (±2.4) 79.8 (±6.3) 84.4 (±4.6) 81.8 (±5.1) 68.7 (±8.1) 59.4 (±8.7) 51.7 (±8.9) 37.1 (±8.5) 25.0 (±7.5) 18.1 (±6.8) §§§ §§§ §§§ Dist. of Columbia 85.9 (±8.6) 82.1 (±10.2) 83.1 (±8.3) 91.3 (±7.0) 55.6 (±14.6) 43.0 (±14.4) 30.2 (±12.3) 67.7 (±13.9) 40.2 (±14.5) 24.5 (±13.0) §§§ Maryland 93.8 (±3.9) 78.9 (±7.1) 83.2 (±6.2) 78.0 (±6.6) 50.0 (±11.5) 45.5 (±11.4) 33.4 (±10.7) 34.2 (±10.2) 23.1 (±9.0) NA §§§ §§§ §§§ Pennsylvania 93.8 (±2.8) 92.1 (±3.4) 89.9 (±3.5) 90.4 (±3.6) 59.5 (±8.1) 53.5 (±8.2) 45.9 (±8.1) 44.1 (±7.8) 26.8 (±6.9) 15.4 (±5.5) PA-Philadelphia 90.2 (±4.6) 91.8 (±4.5) 89.6 (±4.1) 92.1 (±3.8) 78.4 (±7.3) 71.2 (±8.0) 54.5 (±9.1) 55.8 (±9.7) 35.7 (±8.9) 15.8 (±6.2) §§§ §§§ PA-Rest of State 94.3 (±3.1) 92.2 (±3.8) 89.9 (±3.9) 90.2 (±4.0) 57.0 (±9.0) 51.1 (±9.1) 44.7 (±9.1) 42.7 (±8.7) 25.7 (±7.7) 15.4 (±6.2) §§§ Virginia 92.0 (±4.9) 68.0 (±9.1) 83.6 (±6.5) 64.2 (±8.5) 51.9 (±12.7) 41.4 (±12.3) 27.6 (±10.6) 26.4 (±10.6) 22.4 (±10.4) NA §§§ West Virginia 83.2 (±4.8) 59.4 (±8.1) 76.7 (±5.6) 77.3 (±5.5) 49.7 (±9.4) 43.6 (±9.2) 38.4 (±9.0) 29.4 (±8.5) 19.2 (±7.3) 15.1 (±6.6) ¶¶¶ §§§ §§§ §§§ §§§ §§§ §§§ HHS Region IV 92.2 (±1.6) 76.5 (±2.8) 82.5 (±2.3) 70.9 (±2.6) 53.0 (±4.1) 42.9 (±4.1) 33.9 (±3.9) 28.4 (±3.8) 18.6 (±3.2) 11.1 (±2.6) §§§ Alabama 93.4 (±3.2) 79.1 (±6.1) 87.3 (±4.5) 69.5 (±6.0) 54.7 (±9.2) 46.6 (±9.2) 39.6 (±9.0) 18.4 (±6.9) 10.9 (±5.2) NA Florida 93.5 (±3.8) 76.0 (±7.0) 84.8 (±5.4) 72.3 (±6.4) 49.7 (±10.2) 40.7 (±10.0) 34.3 (±9.8) 27.8 (±8.6) 16.0 (±6.6) 13.2 (±6.2) §§§ §§§ Georgia 96.4 (±3.1) 93.7 (±5.2) 82.0 (±6.6) 76.9 (±7.0) 53.7 (±10.8) 42.3 (±10.4) 33.2 (±9.5) 40.5 (±11.5) 31.0 (±10.7) 15.3 (±8.2) Kentucky 92.7 (±3.7) 66.5 (±7.7) 84.4 (±5.1) 71.2 (±6.3) 47.6 (±9.8) 38.6 (±9.5) 26.8 (±8.5) 19.0 (±7.4) 10.8 (±5.2) NA §§§ §§§ Mississippi 92.3 (±3.9) 55.7 (±8.2) 60.2 (±6.7) 50.1 (±6.9) 53.1 (±9.5) 35.6 (±9.3) 25.2 (±8.6) 13.6 (±6.6) NA NA ¶¶¶ §§§ §§§ North Carolina 87.1 (±4.7) 74.0 (±6.6) 89.4 (±4.0) 72.4 (±5.7) 59.3 (±9.5) 47.4 (±9.7) 32.8 (±9.1) 33.2 (±8.8) 24.4 (±8.0) 12.4 (±6.3) §§§ §§§ §§§ §§§ South Carolina 91.0 (±3.8) 58.6 (±8.1) 71.9 (±6.6) 68.7 (±6.6) 60.4 (±9.7) 53.0 (±10.1) 40.7 (±10.4) 22.2 (±9.0) 13.1 (±6.7) NA Tennessee 88.4 (±4.6) 79.7 (±6.5) 80.0 (±5.4) 67.8 (±6.1) 48.9 (±9.5) 39.8 (±9.4) 35.9 (±9.1) 28.9 (±8.2) 18.0 (±7.1) NA §§§ §§§ §§§ §§§ §§§ §§§ ††† ††† ††† HHS Region V 93.6 (±1.3) 83.0 (±2.4) 86.3 (±1.9) 79.9 (±2.1) 57.4 (±3.8) 46.1 (±3.8) 35.0 (±3.6) 28.3 (±3.4) 18.2 (±2.9) 12.2 (±2.5) §§§ §§§ §§§ §§§ §§§ §§§ §§§ Illinois 93.5 (±2.5) 79.9 (±5.1) 86.2 (±4.2) 79.0 (±4.5) 53.2 (±7.6) 42.6 (±7.5) 33.8 (±7.2) 34.8 (±7.5) 21.2 (±6.6) 16.5 (±6.4) §§§ IL-City of Chicago 88.8 (±5.4) 79.4 (±8.3) 89.7 (±5.2) 83.3 (±6.3) 61.8 (±12.7) 49.2 (±12.8) 38.6 (±12.1) 50.0 (±11.7) 29.1 (±10.4) 19.8 (±8.5) §§§ §§§ §§§ §§§ §§§ §§§ §§§ IL-Rest of State 94.6 (±2.8) 80.0 (±6.1) 85.4 (±5.0) 78.0 (±5.4) 51.2 (±9.0) 41.1 (±8.9) 32.6 (±8.5) 31.4 (±8.9) 19.4 (±7.8) 15.8 (±7.6) Indiana 93.7 (±3.1) 91.8 (±4.2) 90.6 (±3.3) 93.5 (±2.7) 54.1 (±8.3) 44.2 (±8.2) 34.6 (±7.7) 18.2 (±6.3) 13.5 (±5.6) 8.1 (±4.3) §§§ §§§ Michigan 94.0 (±3.4) 92.2 (±3.8) 81.0 (±5.2) 90.7 (±3.9) 66.0 (±9.1) 49.4 (±9.9) 34.5 (±9.4) 30.0 (±8.1) 16.8 (±6.7) 7.7 (±4.5) Minnesota 94.0 (±3.2) 86.3 (±6.0) 91.4 (±3.8) 66.3 (±6.2) 59.3 (±9.3) 45.8 (±9.4) 37.6 (±9.0) 22.0 (±6.7) 13.1 (±5.6) 8.6 (±4.5) §§§ §§§ §§§ Ohio 92.9 (±3.4) 66.2 (±7.4) 84.4 (±4.9) 69.2 (±6.1) 54.8 (±9.3) 47.6 (±9.4) 35.0 (±8.8) 26.5 (±8.2) 19.7 (±7.1) 14.7 (±6.4) §§§ §§§ Wisconsin 93.9 (±3.2) 93.4 (±3.7) 89.6 (±4.2) 81.4 (±4.9) 59.4 (±9.1) 47.8 (±9.4) 36.8 (±9.0) 31.7 (±8.5) 20.9 (±7.7) 13.7 (±6.7) §§§ §§§ §§§ §§§ HHS Region VI 89.0 (±2.5) 77.8 (±3.5) 84.9 (±2.6) 81.5 (±2.5) 56.2 (±5.2) 46.9 (±5.3) 38.1 (±5.2) 33.1 (±4.6) 24.2 (±4.2) 14.5 (±3.3) §§§ Arkansas 89.5 (±3.8) 59.6 (±7.6) 77.7 (±5.3) 40.4 (±6.5) 44.3 (±9.3) 35.4 (±8.9) 24.4 (±8.0) 17.7 (±7.5) NA NA §§§ Louisiana 97.4 (±2.4) 89.1 (±4.4) 87.9 (±4.5) 87.7 (±4.4) 59.8 (±9.2) 54.1 (±9.6) 42.1 (±9.8) 27.0 (±8.1) 20.5 (±7.6) 13.5 (±6.6) §§§ §§§ §§§ §§§ §§§ §§§ §§§ New Mexico 92.3 (±3.1) 72.5 (±6.3) 85.6 (±4.5) 70.9 (±5.6) 67.1 (±8.6) 56.1 (±9.2) 44.3 (±9.2) 31.4 (±7.6) 27.0 (±7.2) 19.2 (±6.6) §§§ §§§ Oklahoma 89.5 (±3.4) 67.3 (±6.2) 78.1 (±4.9) 66.2 (±5.4) 54.8 (±8.7) 46.5 (±8.7) 35.4 (±8.3) 45.2 (±7.5) 31.1 (±6.9) 17.3 (±5.7) §§§ §§§ §§§ Texas 87.3 (±3.6) 79.4 (±4.9) 86.1 (±3.6) 87.6 (±3.5) 56.2 (±7.4) 46.3 (±7.4) 38.9 (±7.4) 34.1 (±6.5) 25.2 (±5.9) 15.0 (±4.6) §§§ TX-Bexar County 87.0 (±4.4) 78.9 (±6.2) 86.6 (±4.5) 87.2 (±4.2) 54.8 (±9.1) 45.7 (±9.2) 32.5 (±8.8) 32.4 (±8.7) 19.1 (±6.9) 9.6 (±4.7) TX-City of Houston 86.8 (±5.3) 82.1 (±7.2) 86.5 (±5.6) 91.4 (±4.6) 62.0 (±10.8) 51.9 (±11.3) 33.9 (±10.6) 40.3 (±9.8) 27.8 (±8.5) 17.5 (±7.0) §§§ §§§ §§§ TX-Rest of State 87.3 (±4.1) 79.2 (±5.6) 86.0 (±4.1) 87.4 (±4.0) 55.9 (±8.6) 45.9 (±8.6) 39.8 (±8.5) 33.7 (±7.4) 25.4 (±6.8) 15.2 (±5.3) See table footnotes on next page. were primarily observed in the last quarter of the year, which Whereas eight states had 2-dose coverage >95%, 13 states and could reflect the impact of health promotion activities initiated the District of Columbia had 2-dose coverage <90%, reflecting during the summer and fall of 2013. a vulnerability to measles transmission. The high number of measles cases reported in the United In 2013, there were racial and ethnic differences for some States in 2014 (580 cases through July 18) (http://www.cdc. vaccines (MenACWY, MMR, and HPV). Compared with gov/measles/index.html) is a reminder of the importance of whites, vaccination coverage among Hispanics was higher for ≥1 achieving and maintaining high 2-dose MMR vaccination cov- MenACWY dose and each HPV dose among males and females, erage among children and adolescents throughout the country. but lower for ≥2 MMR doses. Vaccination coverage was similar 630 MMWR / July 25, 2014 / Vol. 63 / No. 29 Morbidity and Mortality Weekly Report TABLE 3. (Continued) Estimated vaccination coverage with selected vaccines and doses* among adolescents aged 13–17 years by HHS region and state/selected local area — National Immunization Survey–Teen (NIS-Teen), United States, 2013 Females (n = 8,264) Males (n = 9,554) § ¶ †† §§ ¶¶ §§ ¶¶ ≥2 MMR ≥2 VAR ≥1 Tdap** ≥1 MenACWY ≥1 HPV ≥2 HPV ≥3 HPV*** ≥1 HPV ≥2 HPV ≥3 HPV*** Regional/State/ ††† Local area % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) §§§ §§§ §§§ HHS Region VII 89.0 (±2.5) 67.4 (±4.5) 82.4 (±2.9) 62.5 (±3.7) 49.7 (±5.6) 41.7 (±5.4) 31.7 (±4.9) 26.0 (±4.4) 16.6 (±3.5) 9.4 (±2.7) §§§ Iowa 90.2 (±4.0) 62.1 (±7.4) 79.6 (±5.0) 63.6 (±5.9) 57.0 (±8.7) 52.2 (±8.8) 41.9 (±8.8) 30.3 (±8.0) 24.0 (±7.3) 13.7 (±5.4) ¶¶¶ §§§ Kansas 86.9 (±4.6) 80.7 (±6.1) 84.6 (±4.9) 55.9 (±6.8) 39.9 (±9.9) 29.9 (±9.2) 21.0 (±8.2) 25.1 (±8.6) 19.3 (±7.8) NA Missouri 88.3 (±4.8) 58.6 (±8.6) 81.5 (±5.4) 60.7 (±7.1) 46.1 (±10.6) 38.1 (±10.1) 28.8 (±9.0) 20.5 (±7.7) NA NA §§§ §§§ §§§ Nebraska 92.3 (±3.2) 84.6 (±5.5) 86.1 (±4.7) 77.5 (±5.2) 65.1 (±9.2) 55.3 (±9.3) 41.5 (±9.1) 38.2 (±8.7) 26.4 (±7.8) 19.7 (±7.2) HHS Region VIII 91.0 (±2.1) 71.8 (±3.8) 86.1 (±2.5) 67.0 (±3.3) 52.6 (±5.0) 43.4 (±5.0) 33.1 (±4.7) 24.3 (±4.4) 16.6 (±3.8) 8.6 (±2.5) ¶¶¶ Colorado 92.4 (±3.3) 78.5 (±5.7) 87.1 (±4.4) 73.6 (±5.6) 58.2 (±8.6) 50.0 (±8.8) 39.1 (±8.7) 33.5 (±8.6) 21.7 (±7.5) 9.9 (±4.8) ¶¶¶ Montana 90.5 (±4.0) 58.6 (±8.6) 84.3 (±5.1) 51.6 (±6.6) 45.8 (±9.6) 37.9 (±9.0) 28.3 (±8.1) 23.8 (±8.1) 17.2 (±7.0) 9.4 (±4.6) §§§ §§§ §§§ §§§ North Dakota 96.1 (±1.9) 86.0 (±5.3) 95.0 (±2.9) 93.7 (±3.2) 57.5 (±9.4) 51.0 (±9.4) 41.1 (±9.1) 36.1 (±9.1) 26.6 (±8.4) 18.4 (±7.5) §§§ South Dakota 94.1 (±3.2) 50.6 (±8.4) 70.0 (±6.4) 51.7 (±6.7) 56.0 (±9.7) 52.0 (±9.7) 42.3 (±9.6) 22.1 (±7.1) 17.0 (±6.4) 8.4 (±4.2) Utah 87.5 (±4.6) 62.2 (±8.4) 86.2 (±4.9) 61.0 (±6.7) 44.3 (±9.6) 30.9 (±8.9) 20.5 (±7.8) 11.0 (±5.8) NA NA §§§ Wyoming 90.6 (±4.0) 90.1 (±4.5) 92.3 (±3.0) 63.1 (±6.2) 54.3 (±9.4) 49.5 (±9.4) 42.1 (±9.3) 16.6 (±6.0) 12.3 (±5.3) 8.4 (±4.5) §§§ §§§ HHS Region IX 90.7 (±3.4) 77.4 (±5.2) 89.7 (±3.5) 80.6 (±4.5) 66.0 (±7.5) 54.8 (±8.0) 43.3 (±8.1) 48.7 (±7.8) 32.5 (±7.7) 16.4 (±6.3) §§§ §§§ Arizona 85.4 (±4.6) 67.8 (±7.1) 84.4 (±5.0) 86.7 (±4.6) 64.1 (±8.7) 47.9 (±9.5) 37.4 (±9.2) 44.4 (±8.7) 33.5 (±8.4) 19.5 (±6.9) §§§ §§§ California 91.5 (±4.2) 79.0 (±6.5) 91.1 (±4.4) 80.9 (±5.7) 67.6 (±9.4) 57.3 (±10.0) 45.8 (±10.2) 50.9 (±9.7) 33.2 (±9.7) 16.6 (±8.0) Hawaii 90.4 (±4.5) 83.3 (±5.7) 80.2 (±5.4) 75.0 (±6.0) 52.7 (±10.1) 46.6 (±10.0) 34.4 (±9.5) 39.7 (±8.9) 29.0 (±8.1) 15.1 (±6.0) §§§ Nevada 92.8 (±3.5) 74.6 (±6.6) 88.3 (±4.1) 64.0 (±6.1) 53.8 (±9.4) 38.9 (±9.2) 27.4 (±8.3) 31.9 (±8.5) 20.4 (±7.2) 7.3 (±3.9) §§§ §§§ §§§ §§§ HHS Region X 90.0 (±2.4) 75.3 (±4.6) 84.1 (±3.0) 72.7 (±3.5) 61.0 (±5.8) 51.2 (±5.9) 40.7 (±5.9) 32.0 (±5.0) 19.3 (±4.0) 11.6 (±3.2) §§§ §§§ Alaska 92.0 (±3.7) 80.7 (±6.1) 74.3 (±5.8) 55.2 (±6.5) 52.2 (±9.4) 36.1 (±9.0) 27.1 (±8.2) 27.6 (±7.9) 17.8 (±6.9) 8.5 (±4.7) §§§ §§§ Idaho 85.2 (±5.5) 63.8 (±9.4) 74.6 (±6.6) 71.6 (±7.0) 55.0 (±10.6) 45.8 (±10.5) 31.3 (±9.6) 34.5 (±10.2) 21.6 (±8.8) NA §§§ §§§ §§§ Oregon 92.3 (±3.2) 84.3 (±4.7) 87.0 (±4.3) 65.3 (±5.8) 66.3 (±8.4) 54.9 (±8.8) 39.5 (±8.8) 35.8 (±8.1) 20.8 (±6.9) 12.2 (±5.0) §§§ §§§ Washington 89.9 (±4.0) 71.6 (±8.1) 86.2 (±5.0) 79.0 (±5.6) 60.7 (±9.7) 52.3 (±9.9) 45.3 (±9.8) 29.8 (±8.0) 18.0 (±6.3) 12.5 (±5.2) Range (83.2–97.4) (50.6–95.8) (60.2–95.5) (40.4–93.7) (39.9–76.6) (29.9–68.5) (20.5–56.5) (11.0–69.3) (10.8–58.0) (7.3–43.2) Territory Guam 84.8 (±4.6) 43.7 (±8.5) 73.8 (±5.4) 72.4 (±5.7) 69.1 (±8.2) 45.2 (±8.9) 33.6 (±8.3) 21.8 (±7.0) 8.6 (±4.2) NA U.S. Virgin Islands 92.0 (±3.0) 77.9 (±5.3) 76.4 (±5.2) 38.4 (±6.0) 33.2 (±8.5) 17.7 (±6.7) 9.5 (±4.9) 17.2 (±6.6) NA NA Abbreviations: CI = confidence interval; HHS = U.S. Department of Health and Human Services; MMR = measles, mumps, and rubella; VAR = varicella; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY = meningococcal conjugate; HPV = human papillomavirus; NA = not available (estimate not reported because unweighted sample size for the denominator was <30 or 95% CI half width/estimate >0.6). * Vaccination estimates for additional measures, including ≥3 doses hepatitis B, and ≥1 dose varicella vaccines are available at http://www.cdc.gov/vaccines/stats-surv/nis/default. htm#nisteen. Adolescents (N = 18,264) in the 2013 NIS-Teen were born January 11, 1995, through February 13, 2001. ≥2 doses of MMR vaccine. ≥2 doses of VAR vaccine among adolescents without a reported history of varicella. ** ≥1 dose Tdap vaccine on or after age 10 years. †† ≥1 dose of MenACWY or meningococcal-unknown type vaccine. §§ ≥1 dose of HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. For ≥1, ≥2, and ≥3 dose measures, separate percentages are reported among females only (n = 8,710) and among males only (n = 9,554). ¶¶ ≥2 doses of HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. *** ≥3 doses of HPV vaccine, either quadrivalent or bivalent may be used for females, and only quadrivalent may be used for males. ††† Estimates with 95% CI half-widths >10 might not be reliable. §§§ Statistically significant (p<0.05) percentage point increase from 2012. ¶¶¶ Statistically significant (p<0.05) percentage point decrease from 2012. by poverty level except for HPV vaccination, with higher coverage However, the significantly lower rates of HPV vaccine series with ≥1, ≥2, and ≥3 HPV doses for males and ≥1 and ≥2 HPV completion in black females compared with white females war- doses for females among those living below poverty level com- rants investigation of possible differences (e.g., access to quality pared with those living at or above the poverty level. The higher care, such as access to clinicians with reminder-recall systems) coverage among some racial/ethnic minorities and those living that might limit vaccine series completion in some populations. below poverty level might be partly attributable to the continued Learning what factors are fostering achievement of increasing and effectiveness of the Vaccines for Children program (VFC), which comparatively higher HPV vaccination coverage among Hispanic provides recommended vaccines at no cost to eligible children.**** adolescents might inform strategies for the general population. The similar or higher vaccination coverage among adolescents living **** Children aged ≤18 years who are Medicaid-eligible, uninsured, or American below the poverty threshold contrasts with findings for coverage Indian/Alaska Native (as defined by the Indian Health Care Improvement Act) are eligible to receive vaccines from providers through the VFC program. Children with some early childhood vaccinations (10). Among children categorized as “underinsured” (because their health plans do not include coverage aged 19–35 months, poverty has been associated with lower for recommended vaccinations) are eligible to receive VFC vaccines if they are coverage of newer vaccines (e.g., rotavirus), and some vaccines served by a rural health clinic or federally qualified health center or under an approved deputization agreement. Additional information is available at http:// www.cdc.gov/vaccines/programs/vfc/providers/eligibility.html. MMWR / July 25, 2014 / Vol. 63 / No. 29 631 Morbidity and Mortality Weekly Report from 2012 to 2013 in only five states (Illinois, Michigan, New What is already known on this topic? Hampshire, New Mexico, and South Carolina) for ≥1 HPV The Advisory Committee on Immunization Practices (ACIP) dose and in four states (Illinois, Mississippi, New Mexico, recommends that adolescents receive 1 dose of tetanus toxoid, and South Carolina) for ≥3 HPV doses. These states have reduced diphtheria toxoid and acellular pertussis (Tdap) undertaken diverse initiatives that likely contributed to the vaccine, 2 doses of meningococcal conjugate (MenACWY ) vaccine, and 3 doses of human papillomavirus (HPV ) vaccine. significant increases in HPV vaccination coverage, including ACIP also recommends administration of these and all age- 1) developing partnerships with state chapters of the American appropriate vaccines during a single visit. During 2006–2012, Academy of Pediatrics and with the Academy of Family national vaccination coverage for ≥1 Tdap and ≥1 MenACWY Physicians to promote HPV immunization, 2) working actively increased steadily, with Tdap coverage in 2011 reaching with Immunization Coalitions and Cancer Collaboratives national target levels for adolescents. During 2007–2011, to incorporate HPV immunization into strategic plans and coverage for ≥1 HPV vaccine dose among females increased steadily, but from 2011 to 2012, there were no changes in ensuring that clinical and immunization conferences highlight coverage. Coverage for ≥1 HPV vaccine dose among males HPV vaccination topics, 3) developing an HPV Vaccine Task increased from 2011-2012. Force to discuss and facilitate HPV vaccination health promo- What is added by this report? tion activities and interventions, 4) providing peer-to-peer From 2012 to 2013, vaccination coverage among U.S. adoles- physician HPV vaccination training onsite, and 5) increasing cents increased to 86.0% for ≥1 dose of Tdap vaccine, 77.8% for provider assessment and feedback visits focused on increasing ≥1 dose of MenACWY vaccine, 57.3% for ≥1 dose of HPV vaccine vaccination coverage among adolescents. Understanding the among females, and 34.6% for ≥1 dose of HPV vaccine among extent to which vaccination programs and policies, provider males. Vaccination coverage levels continued to vary widely practices, and parental knowledge and access influence these among states. Although HPV vaccination coverage increased among both females and males, levels are still low and reflect geographic differences might help inform public health action. many missed opportunities. Five states had substantial The findings in this report are subject to at least three increases in HPV coverage from 2012 to 2013, suggesting limitations. First, the household response rates for landline greater progress is feasible. and cell phone samples were 51.1% and 23.3%, respectively. What are the implications for public health practice? Furthermore, only 59.5% of landline and 54.5% of cell phone Lower vaccination coverage for HPV compared with Tdap and completed interviews had adequate vaccine provider data. MenACWY vaccines indicates clinicians, parents, and adoles- Therefore, estimates might have been biased, even after weight- cents are missing opportunities for infection and cancer ing adjustments for nonresponse and exclusion of households prevention. Clinician recommendations strongly influence the without telephones. A total survey error model of 2011 NIS- decisions of parents to vaccinate their children; to maximize coverage, clinicians should clearly and consistently recommend Teen that included comparison with provider-reported data all ACIP-recommended vaccines, including HPV. Health care collected from a sample of National Health Interview Survey systems interventions, including use of client reminder and participants indicated coverage estimates were approximately recall systems, immunization information systems, clinician 2, 3, and 6 percentage points too high for Tdap, MenACWY, reminders, and standing orders, should be employed to and HPV (among females) vaccinations, respectively, as a result improve protection of adolescents from vaccine-preventable †††† Estimates of bias do infections and future cancers. of noncoverage and nonresponse error. not include errors in vaccination status (e.g., underascertain- ment from incomplete vaccination provider identification and that require doses during the second year of life (e.g., DTaP unknown medical record completeness) (7). Second, although and PCV) (10). response rates have been stable in recent years and weights Geographic differences in coverage continue to vary by have been adjusted to reflect the increasing prevalence of cell vaccine. Factors contributing to state or regional differences phone–only households over time, it is possible that nonre- might include different state school vaccination requirements, sponse bias might have changed over time, which could affect different stages of vaccine policy implementation, increased interpretation of comparisons across data years. Finally, some vaccine demand in response to local disease, differing parental of the state-specific and racial/ethnic-specific analyses might knowledge and attitudes toward or access to vaccination, incon- be unreliable because of small sample sizes (7). Estimates with sistent clinician adherence to and knowledge about vaccine confidence half-widths wider than 10 are less reliable, and this recommendations, and other factors. Although there was an impacts estimates for some racial and ethnic populations. For overall increase in HPV vaccination coverage among females, there was continued wide variability among states and HHS †††† Additional information available at http://www.amstat.org/meetings/ Regions. HPV coverage among females increased significantly jsm/2012/onlineprogram/abstractdetails.cfm?abstractid=304324. 632 MMWR / July 25, 2014 / Vol. 63 / No. 29 Morbidity and Mortality Weekly Report HPV coverage analyses by state and sex, small sample sizes References decrease the power to detect differences. 1. Akinsanya-Beysolow I, Advisory Committee on Immunization Practices (ACIP), ACIP Child/Adolescent Immunization Work Group. Advisory High Tdap coverage levels among adolescents aged 13–17 Committee on Immunization Practices recommended immunization years indicate that similar coverage levels are attainable for schedules for persons aged 0 through 18 years—United States, 2014. other vaccines recommended for adolescents. Improved adher- MMWR 2014;63:108–9. 2. CDC. Recommendations on the use of quadrivalent human ence of clinicians and parents to the ACIP recommendation papillomavirus vaccine in males—Advisory Committee on Immunization to administer all age-appropriate vaccines during a single visit Practices (ACIP), 2011. MMWR 2011;60:1705–8. could substantially increase lagging vaccination coverage levels. 3. CDC. General recommendations on immunization: recommendations At each encounter with a clinician, every adolescent’s immu- of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2). nization history should be reviewed to ensure complete vac- 4. US Department of Health and Human Services. Healthy People 2020. cination consistent with ACIP recommendations. Additionally, Washington, DC: US Department of Health and Human Services; 2012. clinicians should provide strong, consistent recommendations Available at http://www.healthypeople.gov/2020/topicsobjectives2020/ objectiveslist.aspx?topicId-23. for all ACIP-recommended vaccines. HPV vaccine should be 5. Community Preventive Services Task Force. Increasing appropriate recommended with the same emphasis and at the same time vaccination. Atlanta, GA: Community Preventive Services Task Force; 2014. as the other vaccines for adolescents. Recommended strategies Available at http://www.thecommunityguide.org/vaccines/index.html. 6. CDC. Updated recommendations for use of meningococcal conjugate to improve vaccination coverage include use of combinations vaccines—Advisory Committee on Immunization Practices (ACIP), of strategies such as patient reminder and recall systems, 2010. MMWR 2011;60:72–6. standing orders, and use of immunization information sys- 7. CDC. National and state vaccination coverage among adolescents aged 13–17 years—United States, 2012. MMWR 2013;62:685–93. tems (5). Coverage levels should continue to be monitored 8. Holmon DM, Bernard V, Roland KB, Watson M, Liddon N, Stokley to describe coverage disparities, to use estimates to identify S. Barriers to human papillomavirus vaccination among U.S. adolescents: target populations for interventions to increase coverage, and a systematic review of the literature. JAMA Pediatr 2014;168:76–82. to inform development of additional policies that will sup- 9. Stokley S, Jeyarajah J, Yankey D, et al. Human papillomavirus vaccination coverage among adolescents, 2007–2013, and postlicensure vaccine safety port further efforts to reduce vaccine-preventable diseases, monitoring, 2006–2014—United States. MMWR 2014;63:620–4. including cancers. 10. CDC. National, state, and local area vaccination coverage among children aged 19–35 months—United States, 2012. MMWR 2013;62:733–40. Immunization Services Division, National Center for Immunization and Respiratory Diseases; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases; Division of Sexually Transmitted Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (Corresponding contributor: Laurie D. Elam-Evans, [email protected], 404-718-4838) MMWR / July 25, 2014 / Vol. 63 / No. 29 633

Journal

MMWR. Morbidity and Mortality Weekly Report – Pubmed Central

Published: Jul 25, 2014

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