Discussion

In 2018, U.S. adolescent vaccination coverage with ≥1 and ≥2 doses of MenACWY, ≥1 dose of HPV vaccine and being up-to-date with HPV vaccination continued to improve. Coverage with ≥1 Tdap dose remains high but appears to have stabilized. Although HPV vaccination coverage improved, increases among all adolescents were modest compared with increases in previous years and were observed only among males. Since 2011,¶¶ coverage has increased gradually among females and more rapidly among males. However, only approximately half of adolescents have been fully vaccinated for HPV.

HPV vaccination coverage was higher among adolescents whose parent reported receiving a provider recommendation. Thus, the provider recommendation continues to be a strong predictor of HPV vaccination (3,4). However, even when a provider recommendation was given, only 75% accepted the vaccine, suggesting that there are other reasons adolescents are not being vaccinated. Equipping providers with the tools they need to give strong recommendations that emphasize the importance of HPV vaccination in preventing cancer and effectively address parental concerns is a priority, especially in states where provider recommendations were less commonly reported. Resources on the importance of HPV vaccination and videos demonstrating how to give a recommendation are available to facilitate discussion between providers, teens, and their parents (https://www.cdc.gov/vaccines/vpd/hpv/hcp/resources.html).

Coverage disparities persisted for some vaccines by MSA status. The disparity in HPV vaccination coverage by MSA status is not well understood; however, the lower prevalence of provider recommendations in non-MSA areas might be a factor. In one study, parents and guardians in the rural South indicated that they did not have enough information on the vaccine or its purpose (5). Efforts to ensure that rural health care providers have the resources and training necessary to educate parents and guardians about the benefits of HPV vaccination as a cancer prevention tool might increase the number of adolescents protected against diseases caused by HPV.

Vaccination coverage was significantly lower among uninsured adolescents than among those with private insurance. Adolescents without health insurance are eligible to receive vaccines through the Vaccines for Children (VFC) program.*** Lack of parental awareness of (6) and misconceptions about the program, including that it is only for infants and younger children, might serve as barriers (7). Increasing parental awareness and knowledge of the VFC program should improve vaccination coverage among uninsured adolescents. Providers can assist by ensuring that their health care practice routinely screen patients for eligibility and counsel families about the VFC program.

The findings in this report are subject to at least seven limitations. First, the overall Council of American Survey Research Organizations response rate was low, and fewer than half of adolescents with completed interviews had adequate provider data. Second, bias in estimates might remain even after adjustment for household and provider nonresponse and landline-only and phoneless households.††† Third, changes in estimates of vaccination coverage from 2017 to 2018 should be interpreted with caution, given the transition from dual landline- and cellular- to single-cellular telephone-sampling frame in 2018. Fourth, estimates stratified by jurisdiction might be unreliable because of small sample sizes. Fifth, multiple statistical tests were conducted, and a small number might be significant because of chance alone. Sixth, coverage with ≥2 doses of MenACWY and ≥1 dose of MenB might be underestimated because MenB and second MenACWY dose may be administered at age >17 years (1), and NIS-Teen includes adolescents aged 13–17 years. Finally, the “provider recommendation” variable is based on parental report and thus subject to recall bias.

It is encouraging that HPV vaccination coverage among boys continues to increase; however, the lack of an increase among girls is concerning. In the United States, an estimated 34,800 cases of cancer caused by HPV occur each year; 32,100 (92%), including 59% among women, would be preventable by the 9-valent HPV vaccine (8). Although, HPV vaccination has resulted in large declines in the prevalence of vaccine type HPV infections among adolescent girls and young adults (9), as well as decreases in cervical precancers (10), continuing to improve HPV vaccination coverage for all adolescents, male and female, will ensure they are protected from HPV infection and diseases caused by HPV, including cancers.