Printer Friendly

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

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

NIS-Teen is an annual survey that estimates vaccination coverage among adolescents aged 13-17 years in the 50 states, the District of Columbia (DC), selected local areas, and territories. ([paragraph]) NIS-Teen is conducted among parents and guardians of eligible adolescents identified using a random-digit--dialed sample of landline and cellular telephone numbers. ** Parents and guardians are interviewed by telephone about the sociodemographic characteristics of the adolescent and household. Contact information and consent to contact the teen's vaccination providers are requested. When more than one age-eligible adolescent lives in the household, one is randomly selected for participation. Vaccination providers identified during the interview are mailed a questionnaire requesting the vaccination history from the teen's medical record. ([dagger][dagger]) Vaccination coverage estimates are based on provider-reported vaccination histories. This report summarizes national vaccination coverage for 20,949 adolescents (9,845 females [47%] and 11,104 males [53%]) aged 13-17 years with adequate provider data. ([section][section])

Data were weighted and analyzed to account for the complex sampling design of NIS-Teen. NIS-Teen methodology, including methods for weighting and synthesizing provider-reported vaccination histories, has been described previously (3). T-tests were used to assess vaccination coverage differences between 2017 and 2016 and between demographic subgroups (i.e., age, health insurance status, MSA status, race/ethnicity, and poverty level). Weighted linear regression by survey year was used to estimate annual percentage point changes in coverage. Trends in HPV vaccination initiation and HPV UTD status by year of birth were assessed using combined data from 2016 and 2017 NIS-Teen; p-values <0.05 were considered statistically significant.

National Vaccination Coverage

In 2017, coverage with [greater than or equal to] 1 dose of HPV vaccine was 65.5% among teens, an increase of 5.1 percentage points compared with 2016; 48.6% were HPV UTD with the recommended vaccination series, an increase of 5.2 percentage points from 2016 (Table 1) (Figure). Among adolescents surveyed during 2016-2017, HPV vaccination initiation by age 13 years increased an average of 5.9 percentage points for each birth year, from 19.6% (1998 birth cohort) to 56.3% (2004 birth cohort) (Supplementary Figure 1, https://stacks.cdc.gov/view/ cdc/58071). HPV UTD status by age 13 years increased an average of 3.6 percentage points for each birth year, from 7.7% (1998 birth cohort) to 29.8% (2004 birth cohort). Coverage with [greater than or equal to] 1 and [greater than or equal to] 2 MenACWY doses, [greater than or equal to] 2 MMR doses, and [greater than or equal to] 2 VAR doses also increased (Table 1). Coverage with [greater than or equal to] 1 dose of MenB among persons aged 17 years was 14.5% (95% confidence interval [CI] = 12.3%-17.1%).

Vaccination Coverage by Selected Characteristics

Coverage with >1 dose of HPV vaccine and HPV UTD status were higher among adolescents living below the federal poverty level (73.3% and 53.7%, respectively) than among those living at or above the poverty level (62.8% and 46.7%, respectively) ([paragraph][paragraph]) (Table 2). Coverage with >1 dose of HPV vaccine was 10.8 percentage points lower among adolescents living in non-MSAs and 7.0 percentage points lower among those living in MSA nonprincipal cities compared with those living in MSA principal cities (Table 2). These disparities remained after controlling for poverty level. *** HPV UTD status was 10.0 percentage points lower among adolescents living in non-MSAs and 5.5 percentage points lower among those living in MSA nonprincipal cities compared with those living in MSA principal cities (Table 2). After adjusting for poverty level, differences in HPV UTD status did not persist among adolescents living in MSA nonprincipal cities, but did among adolescents living in non-MSAs compared with those living in MSA principal cities. (dagger][dagger][dagger]) [greater than or equal to] 1- and [greater than or equal to] 2-dose MenACWY coverage rates among adolescents living in non-MSAs were 7.4 and 12.0 percentage points lower, respectively, than those among adolescents living in MSA principal cities (Table 2). This disparity remained after controlling for poverty level.[section][section][section] Differences in HPV vaccination coverage by race/ethnicity in 2017 were similar to patterns observed in previous years (Supplementary Table 1, https://stacks.cdc.gov/view/ cdc/58073) (4). Coverage with [greater than or equal to] 1 dose of HPV vaccine and HPV UTD status were 8.8 and 6.6 percentage points higher, respectively, among adolescents enrolled in Medicaid than among those with private insurance only (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/58074). HPV UTD status, [greater than or equal to] 1-dose MenACWY, and [greater than or equal to] 2-dose MenACWY coverage rates were 12.7, 5.0, and 22.6 percentage points lower, respectively, among uninsured adolescents than among those with private insurance (Supplementary Table 2).

State, Local, and Territorial Vaccination Coverage

Vaccination coverage varied by jurisdiction (Table 3). Coverage with [greater than or equal to] 1 dose of Tdap ranged from 78.9% in Alaska to 96.2% in Massachusetts; with [greater than or equal to] 1 dose of MenACWY, from 60.7% in Wyoming to 95.3% in Georgia; and with [greater than or equal to] 1 dose of HPV vaccine, from 46.9% in Wyoming to 91.9% in DC (Table 3) (Supplementary Figure 2, https://stacks.cdc.gov/ view/cdc/58072). HPV UTD status ranged from 28.8% in Mississippi to 78.0% in DC. The largest increases in HPV UTD status from 2016 to 2017 occurred in Virginia (19.8 percentage points), DC (16.0), South Carolina (13.6), Nebraska (12.4), Dallas, Texas (11.8), Louisiana (11.1), North Carolina (10.7), Massachusetts (8.9), Vermont (8.8), and Texas (6.8) (Table 3). During 2013-2017, [greater than or equal to] 1-dose HPV vaccination coverage increased an average of 5.1 percentage points per year nationally; the 5-year average annual increase ranged from 2.2 to 8.5 percentage points. The largest average annual increases were in Virginia (8.5 percentage points), DC (7.5), Montana (7.4), and in Arkansas, Iowa, Utah, and El Paso, Texas (7.3 percentage points each) (Supplementary Table 3, https://stacks. cdc.gov/view/cdc/58075).

Discussion

In 2017, adolescent vaccination coverage with [greater than or equal to] 1 dose of HPV vaccine, [greater than or equal to] 1 and [greater than or equal to] 2 doses of MenACWY, [greater than or equal to] 2 doses of MMR, and [greater than or equal to] 2 doses of VAR increased, while coverage with [greater than or equal to]1 dose of Tdap and [greater than or equal to] 3 doses of HepB remained high. This report includes the first U.S. estimates of [greater than or equal to] 1-dose MenB coverage. Unlike MenACWY, MenB is not routinely recommended for all adolescents, and thus, the low vaccination coverage in adolescents aged 17 years (14.5%) is not unexpected.

In December 2016, a 2-dose HPV vaccine schedule was recommended for persons starting the series at age <15 years, based on data showing noninferior immunogenicity compared with 3 doses (5). This schedule might encourage on-time initiation of the series and facilitate completion; however, it is too early to assess its impact on vaccination coverage. The 5.1 percentage point annual increase in series initiation among all adolescents since 2013 is encouraging. Moreover, on-time vaccination (series completion by age 13 years) has increased approximately four percentage points in each successive birth cohort. Despite these improvements, HPV vaccination initiation remains lower than coverage with Tdap and MenACWY, suggesting ongoing challenges to providing all three vaccines during the same visit. Efforts are under way to promote and improve on-time vaccination, including implementing a new combined Healthcare Effectiveness Data and Information Set measure for adolescent vaccines that assesses receipt of all three routinely recommended adolescent vaccines, including HPV vaccine series completion by age 13 years (6).

HPV vaccine and MenACWY coverage in non-MSA areas remains lower than that in MSA areas. Disparities in coverage by MSA status were not observed for Tdap. Unlike persons living in urban settings, rural residents are less likely to have knowledge of HPV or be aware of HPV vaccine and its importance in cancer prevention (7,8). The overall shortage of health care providers, especially pediatricians, in rural areas might partially explain the lower coverage among rural adolescents (8,9). Health care providers in rural areas serve a broader population base and might be less familiar with adolescent vaccination recommendations. A study including adolescents and parents in rural Alabama identified provider education, better communication with parents and adolescents about the importance of HPV vaccination for preventing cancer, and a strong provider recommendation as being most influential in initiation of HPV vaccination (7). Resources are available to facilitate discussion with adolescents and their parents about the importance of HPV vaccination (https://www.cdc.gov/ hpv/). Further evaluation is needed to identify where teens are receiving Tdap in non-MSAs and better understand the barriers to providing HPV vaccine and MenACWY at these sites.

The findings in this report are subject to at least five limitations. First, the overall household response rate was 25.7% (landline = 51.5%; cell phone = 23.5%), and only 53.6% of landline-completed and 47.1% of cell phone-completed interviews included adequate provider data. Second, bias in estimates might remain after adjustment for household and provider nonresponse and phoneless households. ([paragraph][paragraph][paragraph]) Weights have been adjusted for the increasing number of cell phone-only households over time. Nonresponse bias might change, which could affect comparisons of estimates between survey years. Third, estimates stratified by state/local area might be unreliable because of small sample sizes. Fourth, multiple statistical tests were conducted, and a small number might be significant because of chance alone. Finally, because NISTeen includes adolescents aged 13-17 years, data on receipt of MenACWY or MenB vaccine at age [greater than or equal to] 18 years could not be collected; thus reported coverage with these vaccines might underestimate the proportion of adolescents receiving them (1). HPV vaccination initiation and completion continue to increase. Postintroduction monitoring studies have found reductions in cervical HPV infection, genital warts, and cervical precancers in the United States (10). Protection against HPV-related cancers will continue to increase if adolescents and their parents are educated about the cancer prevention benefits of HPV vaccine and clinicians consistently recommend and simultaneously administer Tdap, MenACWY, and HPV vaccine at age 11-12 years.

Summary

What is already known about this topic?

Vaccines to prevent human papillomavirus (HPV)-associated cancers, diphtheria, pertussis, tetanus, and meningococcal diseases are routinely recommended for persons aged 11-12 years.

What is added by this report?

In 2017, coverage among adolescents aged 13-17 years increased for [greater than or equal to] 1 dose of HPV vaccine and [greater than or equal to] 1 and [greater than or equal to] 2 doses of meningococcal vaccines and remained high for [greater than or equal to] 1 dose of tetanus and diphtheria toxoids and acellular pertussis vaccine. HPV vaccination initiation has increased an average of 5.1 percentage points annually since 2013.

What are the implications for public health care?

The increase in HPV vaccination coverage indicates that further efforts to address barriers to HPV vaccination initiation and series completion likely will lead to greater protection against HPV-associated cancers.

References

(1.) Robinson CL, Romero JR, Kempe A, Pellegrini C; Advisory Committee on Immunization Practices (ACIP) Child/Adolescent Immunization Work Group. Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger--United States, 2017. MMWR Morb Mortal Wkly Rep 2017;66:134-5. https://doi.org/10.15585/mmwr.mm6605e1

(2.) MacNeil JR, Rubin L, Folaranmi T, Ortega-Sanchez IR, Patel M, Martin SW. Use of serogroup B meningococcal vaccines in adolescents and young adults: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep 2015;64:1171-6. https://doi.org/10.15585/mmwr.mm6441a3

(3.) CDC. National Immunization Survey: a user's guide for the 2016 public-use data file. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://www.cdc.gov/vaccines/imz-managers/nis/ downloads/NIS-TEEN-PUF16-DUG.pdf

(4.) Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years--United States, 2016. MMWR Morb Mortal Wkly Rep 2017;66:874-82. https://doi.org/10.15585/mmwr.mm6633a2

(5.) Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination--updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65:1405-8. https://doi.org/10.15585/mmwr.mm6549a5

(6.) National Committee for Quality Assurance. NCQA updates quality measures for HEDIS 2018. Washington, DC: National Committee for Quality Assurance; 2018. http://www.ncqa.org/newsroom/details/ncqaupdates-quality-measures-for-hedis- 2018?ArtMID=11280&ArticleID =85&tabid=2659

(7.) Boyd ED, Phillips JM, Schoenberger YM, Simpson T. Barriers and facilitators to HPV vaccination among rural Alabama adolescents and their caregivers. Vaccine 2018;36:4126-33. https://doi.org/10.1016/j. vaccine.2018.04.085

(8.) Mohammed KA, Subramaniam DS, Geneus CJ, et al. Rural-urban differences in human papillomavirus knowledge and awareness among US adults. Prev Med 2018;109:39-43. https://doi.org/10.1016/j. ypmed.2018.01.016

(9.) Shipman SA, Lan J, Chang CH, Goodman DC. Geographic maldistribution of primary care for children. Pediatrics 2011;127:19-27. https://doi.org/10.1542/peds.2010-0150

(10.) Markowitz LE, Gee J, Chesson H, Stokley S. Ten years of human papillomavirus vaccination in the United States. Acad Pediatr 2018;18(2S):S3-10. https://doi.org/10.1016/j.acap.2017.09.014

Tanja Y. Walker, MPH [1]; Laurie D. Elam-Evans, PhD [1]; David Yankey, PhD [1]; Lauri E. Markowitz, MD [2]; Charnetta L. Williams, MD [1]; Sarah A. Mbaeyi, MD [3]; Benjamin Fredua, MS [1,4]; Shannon Stokley, DrPH [1]

Corresponding author: Tanja Y. Walker, tywalker@cdc.gov, 404-718-8569.

[1] Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC; [2] Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC; 3Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC; 4Leidos Health, Inc., Reston, Virginia.

All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

* Eligible participants were born during January 1999-February 2005. Tdap coverage represents receipt of [greater than or equal to] 1 Tdap dose at age [greater than or equal to] 10 years. MenACWY coverage represents receipt of the quadrivalent meningococcal conjugate vaccine or meningococcal vaccine of unknown type. MenB coverage represents receipt of at least 1 dose of either a 2-dose or 3-dose series, depending upon the vaccine brand. HPV vaccination coverage includes receipt of any HPV vaccine and does not distinguish between nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV) vaccines. Some adolescents might have received more than the 2 or 3 recommended HPV vaccine doses. Estimates for hepatitis B and MMR vaccines represent coverage based on catch up for adolescents who were not up-to-date with these vaccinations. Except as noted, coverage estimates for [greater than or equal to] 1 and [greater than or equal to] 2 varicella vaccine doses were obtained among adolescents with no history of varicella disease. Influenza vaccination coverage data are not included in this report but are available online at https://www.cdc.gov/flu/fluvaxview/ index.htm.

([dagger]) Adolescents were considered to be HPV UTD if they had received >3 doses, or if all of the following applied: 1) they had received 2 doses; 2) the first dose was received before the 15th birthday; and 3) the interval between the first and second doses was [greater than or equal to] 5 months minus 4 days, the absolute minimum interval between the first and second doses. https://www.cdc.gov/vaccines/programs/ iis/cdsi.html.

([section]) MSA status was determined based on household reported city and county of residence, and status was grouped into three categories: MSA principal city, MSA nonprincipal city, and non-MSA. MSA and principal city were as defined by the U.S. Census Bureau (https://www.census.gov/geo/reference/gtc/gtc_cbsa. html). Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.

([paragraph]) The following local areas that received federal Section 317 immunization funds were sampled separately: Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas. Three local areas were oversampled (Dallas County, Texas, El Paso County, Texas, and Travis County, Texas). Three territories were sampled separately in 2017 (Guam, Puerto Rico, and the U.S. Virgin Islands). Because of the severity of 2017's hurricane season, survey operations in Puerto Rico and the U.S. Virgin Islands were suspended resulting in insufficient data for estimation of vaccination coverage.

** All identified cellular-telephone households were eligible for interview. Sampling weights were adjusted for dual-frame (landline and cellular telephone), nonresponse, noncoverage, and overlapping samples of mixed telephone users. A description of NIS-Teen dual-frame survey methodology and its effect on reported vaccination estimates is available at https://www. cdc.gov/vaccines/imz-managers/coverage/nis/child/dual-frame-sampling.html. Starting in 2018, the landline telephone sample was dropped.

([dagger][dagger]) For the telephone samples for the states and local areas, the overall Council of American Survey Research Organizations (CASRO) response rate was 25.7% (51.5% for the landline sample and 23.5% for the cellular-telephone sample). For adolescents with completed interviews, 48.1% had adequate provider data (53.6% landline sample, 47.1% cell sample). Among completed interviews with adequate provider data, 17% (3,572) were from the landline sample, and 83% (17,377) were from the cellular telephone sample. For Guam, the overall CASRO response rate was 31.3%. The CASRO response rate is the product of three other rates: 1) the resolution rate (the proportion of telephone numbers that can be identified as either for business or residence); 2) the screening rate (the proportion of qualified households that complete the screening process); and 3) the cooperation rate (the proportion of contacted eligible households for which a completed interview is obtained).

([section])([section]) Adolescents from Guam (n = 382).

([paragraph][paragraph]) Adolescents were classified as below the federal poverty level if their total family income was less than the federal poverty level specified for the applicable family size and number of children aged <18 years. All others were classified as at or above the poverty level. Poverty status was unknown for 779 adolescents. https://www.census.gov/data/tables/time-series/demo/incomepoverty/historical-poverty-thresholds.html.

*** Among adolescents living below poverty level, >1-dose HPV vaccination coverage estimates stratified by MSA status were 63.7% (95% CI = 58.4%-68.7%) for adolescents living in non-MSAs, 70.4% (CI = 65.8%-74.7%) for adolescents living in MSA nonprincipal cities, and 78.0% (CI = 74.1%-81.5%) for adolescents living in MSA principal cities (reference group). Among adolescents living at or above poverty level, [greater than or equal to] 1-dose HPV vaccination coverage estimates were 56.9% (CI = 53.8%-60.0%) for adolescents living in non-MSAs, 61.6% (CI = 59.6%-63.6%) for adolescents living in MSA nonprincipal cities, and 66.0% (CI = 63.7%-68.2%) for adolescents living in MSA principal cities (reference group).

(dagger][dagger][dagger]) Among adolescents living below poverty level, HPV UTD status estimates stratified by MSA status were 44.3% (CI = 39.1%-49.6%), 52.8% (CI = 47.8%-57.8%), and 57.0% (CI = 52.4%-61.5%) for adolescents living in non-MSAs, MSA nonprincipal cities, and MSA principal cities (reference group), respectively. Among adolescents living at or above poverty level, HPV UTD status estimates stratified by MSA status were 40.7% (CI = 37.6%-48.3%), 46.1% (CI = 44.0%-48.2%), and 49.3% (CI = 46.9% 51.7%) for adolescents living in non-MSAs, MSA nonprincipal cities, and MSA principal cities (reference group), respectively. [section][section][section] Among adolescents living below poverty level, >1-dose MenACWY coverage estimates stratified by MSA status were 83.2% (CI = 79.3%-86.5%), 87.7% (CI = 84.0%-90.7%), and 85.1% (CI = 80.9%-88.5%) for adolescents living in non-MSAs, MSA nonprincipal cities, and MSA principal cities (reference group), respectively. Among adolescents living at or above poverty level, [greater than or equal to] 1-dose MenACWY coverage estimates were 76.0% (CI = 73.1%-78.7%), 85.7% (CI = 84.0%-87.3%), and 86.0% (CI = 84.3%-87.5%) for adolescents living in non-MSAs, MSA nonprincipal cities, and MSA principal cities (reference group), respectively.

([paragraph][paragraph][paragraph]) In a sensitivity analysis of 2013 NIS-Teen data, including adjustments for incomplete sample frame, nonresponse bias, and incomplete ascertainment of vaccination status, estimates of Tdap, [greater than or equal to] 1 dose MenACWY, and [greater than or equal to] 1 dose HPV vaccine coverage, were estimated to be lower than actual values by 1-3 percentage points https://www.cdc.gov/vaccines/imz-managers/nis/ downloads/NIS-TEEN-PUF16-DUG.pdf.

Caption: FIGURE. Estimated coverage with selected vaccines and doses * among adolescents aged 13-17 years, by survey year and ACIP recommendations ([dagger])--National Immunization Survey-Teen, United States, 2006-2017 ([section])
TABLE 1. Estimated vaccination coverage with selected vaccines and
doses among adolescents aged 13-17 * years, by age at interview--
National Immunization Survey-Teen (NIS-Teen), United States, 2017

                                     Age (yrs) % (95% CI) ([dagger])
                                                   13
Vaccine                                        (n = 4,283)

Tdap ([section]) [greater than                       86.4 (84.0-88.4)
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1                         83.6 (81.2-85.8)
  dose
[greater than or equal to] 2                                       NA
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1                     60.7 (57.9-63.5) ***
  dose
UTD ([dagger][dagger][dagger])                   39.0 (36.2-41.8) ***
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1                     64.5 (60.5-68.3) ***
  dose
UTD                                              43.7 (39.6-47.8) ***
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1                         57.1 (53.1-61.0)
  dose
UTD                                                  34.4 (30.8-38.2)
MMR [greater than or equal to]                       93.7 (92.4-94.8)
  2 doses
Hepatitis B vaccine [greater                         93.0 (91.4-94.3)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease                           9.8 (8.2-11.7)
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1                       96.7 (95.6-97.5)
    vaccine dose
  [greater than or equal to] 2                       92.0 (90.2-93.6)
    vaccine doses
History of varicella disease                         92.8 (91.1-94.2)
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

                                     Age (yrs) % (95% CI) ([dagger])
                                                   14
Vaccine                                        (n = 4,429)

Tdap ([section]) [greater than         89.9 (88.0-91.5) ([paragraph])
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1                         85.8 (83.8-87.6)
  dose
[greater than or equal to] 2                                       NA
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1           65.1 (62.5-67.6) ([paragraph])
  dose
UTD ([dagger][dagger][dagger])         48.3 (45.5-51.2) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1                         67.8 (63.8-71.6)
  dose
UTD                                    52.7 (48.3-57.1) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1           62.4 (59.1-65.6) ([paragraph])
  dose
UTD                                    44.1 (40.6-47.6) ([paragraph])
MMR [greater than or equal to]                       91.6 (89.6-93.3)
  2 doses
Hepatitis B vaccine [greater                         92.4 (90.6-93.8)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease                         11.4 (10.0-13.1)
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1                       95.7 (93.9-97.1)
    vaccine dose
  [greater than or equal to] 2                       90.2 (87.9-92.1)
    vaccine doses
History of varicella disease                         91.3 (89.2-93.0)
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

                                     Age (yrs) % (95% CI) ([dagger])
                                                   15
Vaccine                                        (n = 4,212)

Tdap ([section]) [greater than         89.4 (87.7-91.0) ([paragraph])
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1                         85.1 (83.1-86.9)
  dose
[greater than or equal to] 2                                       NA
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1           66.5 (63.8-69.1) ([paragraph])
  dose
UTD ([dagger][dagger][dagger])         50.7 (47.8-53.6) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1                         67.2 (63.4-70.9)
  dose
UTD                                    53.3 (49.1-57.5) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1           65.7 (61.9-69.3) ([paragraph])
  dose
UTD                                    48.1 (44.1-52.2) ([paragraph])
MMR [greater than or equal to]                       92.1 (90.3-93.5)
  2 doses
Hepatitis B vaccine [greater                         91.6 (89.8-93.1)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease           13.7 (11.6-16.1) ([paragraph])
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1                       95.5 (94.2-96.6)
    vaccine dose
  [greater than or equal to] 2         88.8 (86.6-90.7) ([paragraph])
    vaccine doses
History of varicella disease           90.3 (88.4-92.0) ([paragraph])
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

                                     Age (yrs) % (95% CI) ([dagger])
                                                   16
Vaccine                                        (n = 4,218)

Tdap ([section]) [greater than         89.7 (87.7-91.5) ([paragraph])
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1                         86.6 (84.5-88.4)
  dose
[greater than or equal to] 2                                       NA
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1           67.3 (64.7-69.8) ([paragraph])
  dose
UTD ([dagger][dagger][dagger])         52.7 (49.8-55.5) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1           71.5 (67.8-75.0) ([paragraph])
  dose
UTD                                    57.5 (53.3-61.5) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1           63.4 (59.7-67.0) ([paragraph])
  dose
UTD                                    48.2 (44.3-52.1) ([paragraph])
MMR [greater than or equal to]                       91.6 (89.5-93.2)
  2 doses
Hepatitis B vaccine [greater                         90.9 (88.9-92.6)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease           14.9 (12.7-17.4) ([paragraph])
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1         94.4 (92.2-96.0) ([paragraph])
    vaccine dose
  [greater than or equal to] 2         86.1 (83.7-88.2) ([paragraph])
    vaccine doses
History of varicella disease           88.2 (86.1-90.0) ([paragraph])
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

                                     Age (yrs) % (95% CI) ([dagger])
                                                   17
Vaccine                                        (n = 3,807)

Tdap ([section]) [greater than                       88.1 (85.4-90.3)
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1                         84.4 (81.7-86.8)
  dose
[greater than or equal to] 2                         44.3 (41.4-47.2)
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1           68.1 (65.4-70.7) ([paragraph])
  dose
UTD ([dagger][dagger][dagger])         52.5 (49.5-55.4) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1           72.0 (68.1-75.6) ([paragraph])
  dose
UTD                                    58.7 (54.2-63.1) ([paragraph])
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1           64.3 (60.6-67.9) ([paragraph])
  dose
UTD                                    46.4 (42.5-50.4) ([paragraph])
MMR [greater than or equal to]         91.3 (89.4-92.9) ([paragraph])
  2 doses
Hepatitis B vaccine [greater                         91.7 (89.8-93.3)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease           16.5 (14.6-18.6) ([paragraph])
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1                       94.9 (92.8-96.5)
    vaccine dose
  [greater than or equal to] 2         85.4 (82.7-87.7) ([paragraph])
    vaccine doses
History of varicella disease           87.8 (85.5-89.7) ([paragraph])
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

                                       Total % (95% CI) ([dagger])
                                                  2017
Vaccine                                       (n = 20,949)

Tdap ([section]) [greater than                       88.7 (87.8-89.6)
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1       85.1 (84.2-86.1) ([dagger][dagger])
  dose
[greater than or equal to] 2       44.3 (41.4-47.2) ([dagger][dagger])
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1       65.5 (64.3-66.7) ([dagger][dagger])
  dose
UTD ([dagger][dagger][dagger])     48.6 (47.3-49.9) ([dagger][dagger])
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1       68.6 (66.9-70.2) ([dagger][dagger])
  dose
UTD                                53.1 (51.2-55.0) ([dagger][dagger])
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1       62.6 (60.9-64.2) ([dagger][dagger])
  dose
UTD                                44.3 (42.6-46.0) ([dagger][dagger])
MMR [greater than or equal to]     92.1 (91.3-92.8) ([dagger][dagger])
  2 doses
Hepatitis B vaccine [greater                         91.9 (91.1-92.6)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease       13.2 (12.3-14.2) ([dagger][dagger])
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1                       95.5 (94.8-96.1)
    vaccine dose
  [greater than or equal to] 2     88.6 (87.6-89.5) ([dagger][dagger])
    vaccine doses
History of varicella disease       90.1 (89.3-90.9) ([dagger][dagger])
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

                                   Total % (95% CI) ([dagger])
                                              2016
Vaccine                                   (n = 20,475)

Tdap ([section]) [greater than               88.0 (87.1-88.9)
  or equal to] 1 dose
MenACWY **
[greater than or equal to] 1                 82.2 (81.2-83.2)
  dose
[greater than or equal to] 2                 39.1 (36.1-42.1)
  doses ([section][section])
HPV ([paragraph][paragraph])
  vaccine--all adolescents
[greater than or equal to] 1                 60.4 (59.2-61.6)
  dose
UTD ([dagger][dagger][dagger])               43.4 (42.1-44.7)
HPV ([paragraph][paragraph])
  vaccine--females
[greater than or equal to] 1                 65.1 (63.3-66.8)
  dose
UTD                                          49.5 (47.6-51.4)
HPV ([paragraph][paragraph])
  vaccine--males
[greater than or equal to] 1                 56.0 (54.3-57.7)
  dose
UTD                                          37.5 (35.8-39.2)
MMR [greater than or equal to]               90.9 (90.1-91.6)
  2 doses
Hepatitis B vaccine [greater                 91.4 (90.7-92.1)
  than or equal to] 3 doses
Varicella vaccine
History of varicella disease                 15.2 (14.3-16.1)
  ([section][section][section])
No history of varicella disease
  [greater than or equal to] 1               95.0 (94.2-95.6)
    vaccine dose
  [greater than or equal to] 2               85.6 (84.5-86.6)
    vaccine doses
History of varicella disease                 87.8 (86.9-88.6)
  or receipt of [greater than
  or equal to] 2 varicella
  vaccine doses

Abbreviations: CI = confidence interval; HPV = human
papillomavirus; MenACWY = quadrivalent meningococcal conjugate
vaccine; MMR = measles, mumps, and rubella vaccine; NA = not
applicable, Tdap = tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis vaccine; UTD = up-to-date.

* Adolescents (N = 20,949) in the 2017 NIS-Teen were born January
1999 through February 2005.

([dagger]) Estimates with 95% CIs >20 might be unreliable.

([section]) Includes percentages receiving Tdap vaccine at age
[greater than or equal to] 10 years.

([paragraph]) Statistically significant difference (p<0.05) in
estimated vaccination coverage by age; reference group was
adolescents aged 13 years.

** Includes percentages receiving MenACWY or meningococcal vaccine
of unknown type.

([dagger][dagger]) Statistically significant difference (p<0.05)
compared with 2016 NIS-Teen estimates.

([section][section]) [greater than or equal to] 2 doses of MenACWY
or meningococcal vaccine of unknown type. Calculated only among
adolescents who were aged 17 years at interview. Does not include
adolescents who received one dose of MenACWY vaccine at age >16
years.

([paragraph][paragraph]) HPV vaccine, nine-valent (9vHPV),
quadrivalent (4vHPV), or bivalent (2vHPV). For [greater than or
equal to] 1 dose measures, percentages are reported among females
and males combined (N = 20,949) and for females only (N = 9,845)
and males only (N = 11,104).

*** Statistically significant difference (p<0.05) in estimated
vaccination coverage at age 13 years compared with 2016 NIS-Teen
estimates.

([dagger][dagger][dagger]) HPV UTD includes those with [greater
than or equal to] 3 doses, and those with 2 doses when the first
HPV vaccine dose was initiated at age <15 years and at least 5
months minus 4 days elapsed between the first and second dose. This
update to the HPV recommendation occurred in December of 2016.

([section][section][section]) By parent/guardian report or provider
records.

TABLE 2. Estimated vaccination coverage with selected vaccines and
doses among adolescents aged 13-17 years, * by poverty level
([dagger]) and metropolitan statistical area ([section])--National
Immunization Survey-Teen (NIS-Teen), United States, 2017

                                         Poverty status
                                      % (95% CI) ([paragraph])

                                                     At or above
                         Below poverty level        poverty level
Vaccine                      (n = 3,579)            (n = 16,591)

Tdap **                 88.2 (85.7 to 90.4)      88.8 (87.7 to 89.7)
  [greater than or
  equal to] 1 dose
MenACWY ([dagger]
  [dagger])
[greater than or        85.7 (83.2 to 87.8)      84.8 (83.7 to 85.8)
  equal to] 1 dose
[greater than or        46.2 (38.6 to 54.0)      42.8 (39.7 to 45.9)
  equal to] 2 doses
  ([paragraph]
  [paragraph])
HPV ***
[greater than or        73.3 (70.7 to 75.8)      62.8 (61.4 to 64.1)
  equal to] 1 dose        ([section][section])
UTD ([dagger]           53.7 (50.7 to 56.6)      46.7 (45.3 to 48.2)
  [dagger][dagger])       ([section][section])
[greater than or        90.6 (88.4 to 92.5)      92.4 (91.5 to 93.1)
  equal to]2 MMR
  doses
[greater than or        89.9 (87.6 to 91.8)      92.5 (91.7 to 93.3)
  equal to] 3             ([section][section])
  Hepatitis B doses
Varicella
History of varicella    13.8 (12.1 to 15.6)      12.6 (11.6 to 13.6)
  disease ([section]
  [section][section])
No history of
  varicella disease
[greater than or        94.4 (91.9 to 96.1)      95.7 (95.0 to 96.4)
  equal to] 1
  varicella vaccine
  dose
[greater than or        88.2 (85.5 to 90.4)      88.6 (87.6 to 89.6)
  equal to] 2
  varicella vaccine
  doses
History of varicella    89.8 (87.5 to 91.7)      90.1 (89.1 to 90.9)
  or receipt of
  [greater than or
  equal to] 2 doses
  varicella vaccine

                            Poverty status           Metropolitan
                             % (95% CI)          statistical area (MSA)
                            ([paragraph])              % (95% CI)
                                                     ([paragraph])

                              Difference                Non-MSA
Vaccine                      (n = 20,170)             (n = 4,123)

Tdap **                 -0.6 (-3.0 to 2.0)       88.0 (86.0 to 89.8)
  [greater than or
  equal to] 1 dose
MenACWY ([dagger]
  [dagger])
[greater than or        0.9 (-1.7 to 3.4)        78.6 (76.3 to 80.7)
  equal to] 1 dose                                 ([section][section])
[greater than or        3.4 (-4.9 to 11.7)       35.0 (29.6 to 40.8)
  equal to] 2 doses
  ([paragraph]
  [paragraph])
HPV ***                                            ([section][section])
[greater than or        10.5 (7.6 to 13.5)       59.3 (56.6 to 61.9)
  equal to] 1 dose        ([section][section])     ([section][section])
UTD ([dagger]           7.0 (3.6 to 10.3)        42.4 (39.8 to 45.1)
  [dagger][dagger])       ([section][section])     ([section][section])
[greater than or        -1.8 (-3.9 to 0.5)       92.0 (90.6 to 93.3)
  equal to]2 MMR
  doses
[greater than or        -2.6 (-4.8 to 0.3)       91.3 (89.6 to 92.7)
  equal to] 3             ([section][section])
  Hepatitis B doses
Varicella
History of varicella    1.2 (-0.8 to 3.2)        16.1 (14.2 to 18.2)
  disease ([section]
  [section][section])
No history of
  varicella disease
[greater than or        -1.3 (-3.5 to 0.8)       95.4 (94.1 to 96.5)
  equal to] 1
  varicella vaccine
  dose
[greater than or        -0.4 (-3.1 to 2.2)       87.3 (85.4 to 89.1)
  equal to] 2
  varicella vaccine
  doses
History of varicella    -0.3 (-2.6 to 2.0)       89.4 (87.7 to 90.8)
  or receipt of
  [greater than or
  equal to] 2 doses
  varicella vaccine

                            Metropolitan statistical area (MSA)
                                     % (95% CI) ([paragraph])

                           MSA nonprincipal
                                 city            MSA principal city
Vaccine                      (n = 8,282)             (n = 8,544)

Tdap **                 88.9 (87.5 to 90.1)      88.8 (87.2 90.1)
  [greater than or
  equal to] 1 dose
MenACWY ([dagger]
  [dagger])
[greater than or        86.1 (84.6 to 87.4)      86.0 (84.4 to 87.4)
  equal to] 1 dose
[greater than or        44.3 (40.2 to 48.5)      47.0 (42.2 to 51.9)
  equal to] 2 doses
  ([paragraph]
  [paragraph])
HPV ***
[greater than or        63.1 (61.3 to 64.8)      70.1 (68.2 to 71.9)
  equal to] 1 dose        ([section][section])
UTD ([dagger]           46.9 (45.0 to 48.8)      52.4 (50.3 to 54.4)
  [dagger][dagger])       ([section][section])
[greater than or        92.1 (90.9 to 93.1)      92.1 (90.7 to 93.3)
  equal to]2 MMR
  doses
[greater than or        92.0 (90.9 to 93.0)      92.0 (90.6 to 93.1)
  equal to] 3
  Hepatitis B doses
Varicella
History of varicella    12.2 (11.0 to 13.5)      13.6 (12.1 to 15.2)
  disease ([section]
  [section][section])
No history of
  varicella disease
[greater than or        95.6 (94.6 to 96.5)      95.4 (94.0 to 96.4)
  equal to] 1
  varicella vaccine
  dose
[greater than or        88.8 (87.4 to 90.1)      88.7 (87.0 to 90.2)
  equal to] 2
  varicella vaccine
  doses
History of varicella    90.2 (88.9 to 91.3)      90.2 (88.7 to 91.5)
  or receipt of
  [greater than or
  equal to] 2 doses
  varicella vaccine

                            Metropolitan statistical area (MSA)
                                     % (95% CI) ([paragraph])
                                                   Difference between
                          Difference between        MSA nonprincipal
                           non-MSA and MSA              city and
                            principal city           principal city
Vaccine                      (n = 12,667)             (n = 16,826)

Tdap **                 -0.8 (-3.1 to 1.6)       0.1 (-1.8 to 2.1)
  [greater than or
  equal to] 1 dose
MenACWY ([dagger]
  [dagger])
[greater than or        -7.4 (-10.0 to 4.7)      0.1 (-81.2 to 83.2)
  equal to] 1 dose        ([section][section])
[greater than or        -12.0 (-19.5 to 4.6)     -2.7 (-9.1 to 3.7)
  equal to] 2 doses
  ([paragraph]
  [paragraph])
HPV ***                   ([section][section])
[greater than or        -10.8 (-14.0 to 7.6)     -7.0 (-9.6 to 4.4)
  equal to] 1 dose        ([section][section])     ([section][section])
UTD ([dagger]           -10.0 (-13.3 to 6.6)     -5.5 (-8.3 to 2.6)
  [dagger][dagger])       ([section][section])     ([section][section])
[greater than or        0.1 (-1.9 to 1.8)        0.0 (-1.7 to 1.7)
  equal to]2 MMR
  doses
[greater than or        -0.7 (-2.7 to 1.3)       0.0 (-1.6 to 1.7)
  equal to] 3
  Hepatitis B doses
Varicella
History of varicella    2.5 (0.0 to 5.1)         -1.4 (-3.4 to 0.6)
  disease ([section]
  [section][section])
No history of
  varicella disease
[greater than or        0.0 (-1.6 to 1.7)        0.2 (-1.3 to 1.8)
  equal to] 1
  varicella vaccine
  dose
[greater than or        -1.4 (-3.8 to 1.1)       0.1 (-1.9 to 2.3)
  equal to] 2
  varicella vaccine
  doses
History of varicella    -0.8 (-2.9 to 1.3)       0.0 (-1.8 to 1.9)
  or receipt of
  [greater than or
  equal to] 2 doses
  varicella vaccine

Abbreviations: CI = confidence interval; HPV = human
papillomavirus; MenACWY = quadrivalent meningococcal conjugate
vaccine; MMR = measles, mumps, and rubella vaccine; Tdap = tetanus
toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine;
UTD = up-to-date.

* Adolescents (N = 20,949) in the 2017 NIS-Teen were born January
1999 through February 2005.

([dagger]) Adolescents were classified as below poverty level if
their total family income was less than the federal poverty level
specified for the applicable family size and number of children
aged <18 years. All others were classified as at or above the
poverty level. Additional information available at
https://www.census.gov/data/tables/time-series/demo/
income-poverty/historical-poverty-thresholds.html.
Poverty status was unknown for 779 adolescents.

([section]) MSA status was determined based on household-reported
county and city of residence, and was grouped into three
categories: MSA principal city, MSA nonprincipal city, and non-MSA.
MSA and principal city were as defined by the U.S. Census Bureau
(https://www.census.gov/geo/reference/gtc/gtc_cbsa.html). Non-MSA
areas include urban populations not located within an MSA as well
as completely rural areas.

([paragraph]) Estimates with 95% CIs >20 might be unreliable.

** Includes percentages receiving Tdap vaccine at age [greater than
or equal to] 10 years.

([dagger][dagger]) Includes percentages receiving MenACWY and
meningococcal vaccine of unknown type.

([section][section]) Statistically significant difference (p<0.05)
in estimated vaccination coverage by poverty level or metropolitan
statistical area; the referent groups were adolescents living at or
above poverty level and MSA principal city respectively.

([paragraph][paragraph]) [greater than or equal to] 2 doses of
MenACWY or meningococcal vaccine of unknown type vaccine.
Calculated only among adolescents aged 17 years at interview. Does
not include adolescents who received one dose of MenACWY vaccine at
age [greater than or equal to] 16 years.

*** HPV vaccine, nine-valent (9vHPV), quadrivalent (4vHPV), or
bivalent (2vHPV) in females and males combined.

([dagger][dagger][dagger]) HPV UTD includes those with >3 doses and
those with 2 doses when the first HPV vaccine dose was initiated at
age <15 years and at least 5 months minus 4 days elapsed between
the first and second dose. This update to the HPV recommendation
occurred in December of 2016.

([section][section][section]) By parent/guardian report or provider
records.

TABLE 3. Estimated vaccination coverage with selected vaccines and
doses * among adolescents aged 13-17 years, ([dagger]) by HHS region,
state, selected local area, or territory--National Immunization
Survey-Teen (NIS-Teen), United States, 2017

                                  All adolescents (N = 20,949)
                                       % (95% CI) ([section])
Region, state, local area     [greater than or      [greater than or
                               equal to] Tdap         equal to] 1
                                ([paragraph])          MenACWY **

United States overall          88.7 (87.8-89.6)      85.1 (84.2-86.1)
                                                         ([paragraph]
                                                         [paragraph])
Region I                       94.6 (93.1-95.7)      92.5 (90.8-93.9)

Connecticut                    94.9 (91.9-96.8)      94.9 (91.4-97.0)

Maine                          85.1 (79.8-89.3)      83.9 (78.8-88.0)
Massachusetts                  96.2 (93.4-97.8)      94.0 (90.7-96.2)

New Hampshire                  95.1 (91.6-97.2)      87.9 (82.9-91.6)
Rhode Island                   94.6 (91.0-96.8)      94.1 (90.2-96.5)
Vermont                        92.8 (89.2-95.2)      84.2 (78.9-88.3)

Region II                      91.9 (89.7-93.7)      90.6 (88.1-92.6)
New Jersey                     90.0 (85.3-93.3)      93.3 (89.4-95.9)
New York                       92.9 (90.3-94.8)      89.3 (85.9-91.9)
New York-New York City         92.9 (89.0-95.5)      88.8 (83.6-92.6)
New York-rest of state         92.8 (89.1-95.4)      89.5 (84.9-92.9)
Region III                     89.5 (87.0-91.6)     88.8 (86.3-91.0)
                                                         ([paragraph]
                                                         [paragraph])
Delaware                       89.6 (84.5-93.2)      90.5 (85.7-93.7)
District of Columbia           86.1 (80.2-90.4)      91.3 (85.7-94.9)

Maryland                       88.3 (82.2-92.5)      91.8 (86.5-95.1)
                                                         ([paragraph]
                                                         [paragraph])
Pennsylvania                   90.6 (86.7-93.5)      93.4 (90.3-95.6)
Pennsylvania-Philadelphia      91.6 (87.4-94.5)      91.1 (86.8-94.1)
Pennsylvania-rest of state     90.5 (85.9-93.7)      93.7 (90.1-96.0)
Virginia                       89.3 (83.2-93.4)      80.0 (72.6-85.7)

West Virginia                  87.5 (82.8-91.0)      87.9 (83.1-91.5)
Region IV                      90.9 (89.3-92.2)      82.2 (80.0-84.1)
                                                         ([paragraph]
                                                         [paragraph])
Alabama                        88.7 (84.3-92.0)      78.3 (73.0-82.9)
Florida                        91.1 (87.1-94.0)      80.2 (74.3-85.0)
Georgia                        93.3 (89.3-95.9)      95.3 (91.9-97.3)
Kentucky                       86.4 (81.7-90.0)      83.3 (78.3-87.4)
Mississippi                    92.4 (88.6-95.0)      63.0 (56.9-68.7)
                                   ([paragraph]
                                   [paragraph])
North Carolina                 91.9 (87.8-94.7)      84.8 (79.4-89.0)
                                                         ([paragraph]
                                                         [paragraph])
South Carolina                 89.4 (84.5-92.8)      78.6 (72.4-83.7)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Tennessee                      89.4 (84.8-92.8)      75.0 (68.5-80.6)
Region V                       91.8 (90.4-93.0)      89.4 (87.8-90.7)
                                                         ([paragraph]
                                                         [paragraph])
Illinois                       92.4 (89.4-94.6)      89.2 (85.9-91.8)
                                                         ([paragraph]
                                                         [paragraph])
Illinois-Chicago               90.5 (84.9-94.2)      90.9 (83.4-95.2)
Illinois-rest of state         92.8 (89.2-95.3)      88.9 (85.0-91.8)
                                                         ([paragraph]
                                                         [paragraph])
Indiana                        95.1 (92.3-96.9)      93.1 (89.0-95.8)
                                   ([paragraph]
                                   [paragraph])
Michigan                       93.4 (89.2-96.0)      93.5 (89.4-96.1)
Minnesota                      87.5 (82.2-91.4)      87.5 (82.4-91.3)

Ohio                           90.6 (86.9-93.3)      87.3 (83.4-90.4)
                                                         ([paragraph]
                                                         [paragraph])
Wisconsin                      90.3 (85.8-93.5)      83.8 (78.4-88.2)
Region VI                      85.0 (83.0-86.8)      84.4 (82.4-86.2)

Arkansas                       92.4 (88.6-94.9)      91.7 (87.4-94.7)
Louisiana                      90.1 (85.5-93.4)      89.0 (84.3-92.5)

New Mexico                     85.5 (80.3-89.5)      78.0 (72.4-82.8)
Oklahoma                       86.7 (81.7-90.5)      71.1 (64.9-76.6)
Texas                          83.2 (80.4-85.7)      85.1 (82.4-87.5)

Texas-Bexar County             83.7 (77.8-88.3)      86.0 (80.3-90.3)

Texas-Houston                  87.9 (80.2-92.9)      91.4 (85.1-95.2)
Texas-Dallas County            77.0 (69.8-83.0)      85.1 (78.8-89.7)

Texas-El Paso County           89.6 (84.8-93.0)      89.5 (84.4-93.0)
Texas-Travis County            85.9 (80.9-89.8)      89.1 (84.4-92.4)
Texas-rest of state            83.1 (79.3-86.3)      84.1 (80.4-87.2)

Region VII                     86.8 (84.0-89.2)      77.3 (74.2-80.2)
                                                         ([paragraph]
                                                         [paragraph])
Iowa                           93.4 (89.8-95.8)      83.6 (78.4-87.7)
                                                         ([paragraph]
                                                         [paragraph])
Kansas                         89.7 (84.9-93.1)      72.1 (65.8-77.6)
Missouri                       80.1 (74.1-85.0)      74.3 (68.3-79.5)
Nebraska                       92.3 (87.5-95.4)      84.8 (79.4-89.0)

Region VIII                    89.1 (86.6-91.1)     81.4 (78.7-83.8)
                                                         ([paragraph]
                                                         [paragraph])
Colorado                       88.6 (83.6-92.2)      82.4 (77.2-86.6)
Montana                        90.4 (85.8-93.7)      71.2 (64.9-76.8)

North Dakota                   90.6 (86.8-93.5)      91.9 (88.3-94.4)
South Dakota                   79.5 (73.6-84.4)      74.5 (68.4-79.9)
                                                         ([paragraph]
                                                         [paragraph])
Utah                           91.6 (87.7-94.3)      85.1 (80.3-88.9)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Wyoming                        86.4 (81.2-90.3)      60.7 (54.5-66.6)
Region IX                      83.3 (78.5-87.2)      82.2 (77.4-86.2)
Arizona                        82.4 (76.7-87.0)      83.8 (78.3-88.1)
California                     83.5 (77.2-88.3)      82.2 (75.9-87.1)
Hawaii                         84.8 (79.3-89.1)      85.9 (80.6-90.0)
                                                         ([paragraph]
                                                         [paragraph])
Nevada                         82.5 (76.6-87.1)      77.3 (71.0-82.5)
Region X                       87.2 (84.5-89.5)      81.4 (78.2-84.2)
                                                         ([paragraph]
                                                         [paragraph])
Alaska                         78.9 (73.2-83.6)      68.4 (62.5-73.8)
Idaho                          87.3 (82.1-91.1)      90.5 (85.6-93.9)
Oregon                         86.3 (81.6-90.0)      77.0 (71.5-81.8)

Washington                     88.6 (83.8-92.1)      82.6 (77.2-87.0)
Range***                            (78.9-96.2)           (60.7-95.3)
Territory
Guam                           77.3 (71.6-82.1)     68.3 (62.2-73.9)
                                                    ([dagger][dagger]
                                                            [dagger])

                                  All adolescents (N = 20,949)
                                       % (95% CI) ([section])
Region, state, local area     [greater than or     HPV UTD ([section])
                               equal to] 1 HPV
                                 ([dagger])

United States overall          65.5 (64.3-66.7)      48.6 (47.3-49.9)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Region I                       78.2 (75.4-80.8)      63.3 (60.1-66.4)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Connecticut                    71.3 (64.9-76.9)      58.0 (51.4-64.3)
                                   ([paragraph]
                                   [paragraph])
Maine                          75.8 (70.2-80.6)      59.2 (53.2-65.0)
Massachusetts                  81.9 (76.9-85.9)      65.5 (59.7-70.8)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
New Hampshire                  74.2 (68.5-79.2)      59.9 (53.7-65.8)
Rhode Island                   88.6 (83.3-92.4)      77.7 (71.6-82.8)
Vermont                        78.7 (73.2-83.3)      64.5 (58.4-70.2)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Region II                      67.6 (64.1-71.0)      52.3 (48.5-56.0)
New Jersey                     65.8 (59.8-71.3)      49.6 (43.4-55.8)
New York                       68.5 (64.0-72.7)      53.6 (48.9-58.2)
New York-New York City         73.3 (66.9-78.9)      61.0 (54.1-67.5)
New York-rest of state         65.5 (59.3-71.2)      48.8 (42.6-55.0)
Region III                     70.3 (67.0-73.3)      54.5 (51.0-57.9)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Delaware                       75.3 (69.3-80.5)      58.1 (51.6-64.4)
District of Columbia           91.9 (87.6-94.8)      78.0 (71.1-83.6)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Maryland                       69.2 (62.1-75.6)      52.9 (45.4-60.2)

Pennsylvania                   67.3 (62.2-72.1)      52.5 (47.3-57.7)
Pennsylvania-Philadelphia      84.9 (80.0-88.7)      69.5 (63.5-75.0)
Pennsylvania-rest of state     65.0 (59.2-70.4)      50.3 (44.5-56.0)
Virginia                       75.6 (68.4-81.6)      59.0 (51.1-66.6)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
West Virginia                  60.9 (54.6-66.9)      43.9 (37.7-50.2)
Region IV                      60.0 (57.3-62.6)      43.0 (40.3-45.7)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Alabama                        58.0 (52.0-63.9)      40.3 (34.4-46.5)
Florida                        59.8 (53.1-66.1)      42.3 (35.9-49.0)
Georgia                        64.3 (57.5-70.6)      45.7 (39.1-52.5)
Kentucky                       49.6 (43.5-55.6)      37.7 (32.1-43.7)
Mississippi                    49.6 (43.4-55.9)      28.8 (23.5-34.8)

North Carolina                 66.8 (60.4-72.6)      51.9 (45.3-58.4)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
South Carolina                 59.6 (52.7-66.0)      42.7 (36.1-49.5)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Tennessee                      56.1 (49.3-62.6)      39.2 (32.8-46.1)
Region V                       65.5 (63.2-67.8)      49.0 (46.5-51.4)
                                   ([paragraph]          ([paragraph]
                                   [paragraph])          [paragraph])
Illinois                       66.1 (61.5-70.4)      50.4 (45.8-55.0)

Illinois-Chicago               81.9 (73.9-87.8)      66.6 (57.7-74.4)
Illinois-rest of state         62.7 (57.4-67.7)      46.9 (41.7-52.2)

Indiana                            ([paragraph]      40.8 (34.4-47.5)
                                   [paragraph])

Michigan                       67.3 (61.1-73.0)      54.3 (47.9-60.6)
Minnesota                          ([paragraph]      46.9 (40.7-53.3)
                                   [paragraph])

Ohio                           64.1 (58.4-69.3)      47.0 (41.2-52.8)

Wisconsin                      69.2 (63.0-74.8)      52.3 (45.8-58.7)
Region VI                          ([paragraph]      41.3 (38.9-43.8)
                                   [paragraph])          ([paragraph]
                                                         [paragraph])
Arkansas                       61.1 (54.8-67.0)      35.2 (29.4-41.5)
Louisiana                          ([paragraph]      52.9 (46.5-59.1)
                                   [paragraph])          ([paragraph]
                                                         [paragraph])
New Mexico                     66.9 (60.9-72.4)      48.3 (42.2-54.5)
Oklahoma                       58.5 (52.1-64.6)      41.4 (35.3-47.8)
Texas                              ([paragraph]      39.7 (36.5-43.0)
                                   [paragraph])          ([paragraph]
                                                         [paragraph])
Texas-Bexar County                 ([paragraph]      46.4 (40.2-52.7)
                                   [paragraph])

Texas-Houston                  73.0 (63.9-80.4)      55.2 (45.9-64.2)
Texas-Dallas County            54.5 (46.9-62.0)      35.7 (28.8-43.1)
                                                         ([paragraph]
                                                         [paragraph])
Texas-El Paso County           82.8 (77.2-87.2)      60.0 (52.9-66.6)
Texas-Travis County            69.7 (63.3-75.4)      52.0 (45.4-58.5)
Texas-rest of state                ([paragraph]      36.6 (32.4-41.0)
                                   [paragraph])

Region VII                         ([paragraph]      44.2 (40.9-47.6)
                                   [paragraph])

Iowa                               ([paragraph]      53.7 (47.6-59.8)
                                   [paragraph])

Kansas                         52.4 (46.0-58.8)      34.4 (28.6-40.7)
Missouri                       57.8 (51.3-64.0)      39.6 (33.6-45.9)
Nebraska                       71.0 (64.8-76.5)      58.3 (51.9-64.5)
                                                         ([paragraph]
                                                         [paragraph])
Region VIII                        ([paragraph]      46.8 (43.4-50.3)
                                   [paragraph])          ([paragraph]
                                                         [paragraph])
Colorado                       72.1 (66.2-77.3)      53.8 (47.4-60.0)
Montana                            ([paragraph]      49.1 (42.5-55.7)
                                   [paragraph])

North Dakota                   72.5 (67.0-77.4)      57.8 (51.9-63.5)
South Dakota                   63.2 (56.7-69.2)      44.8 (38.5-51.2)

Utah                           58.8 (52.6-64.8)      37.4 (31.5-43.7)

Wyoming                        46.9 (40.8-53.1)      30.9 (25.5-36.8)
Region IX                      70.4 (65.4-75.0)      53.1 (47.5-58.7)
Arizona                        65.0 (58.4-71.2)      53.0 (46.3-59.6)
California                     71.9 (65.4-77.5)      53.4 (46.3-60.4)
Hawaii                         69.4 (63.0-75.1)      54.7 (48.2-61.0)

Nevada                         64.9 (58.3-70.9)      49.0 (42.6-55.5)
Region X                           ([paragraph]      52.8 (48.9-56.6)
                                   [paragraph])          ([paragraph]
                                                         [paragraph])
Alaska                         64.5 (58.4-70.1)      42.6 (36.7-48.8)
Idaho                          62.4 (55.7-68.6)      44.1 (37.6-50.7)
Oregon                             ([paragraph]      54.8 (48.6-60.8)
                                   [paragraph])

Washington                     71.9 (65.8-77.3)      55.2 (48.8-61.5)
Range***                            (46.9-91.9)           (28.8-78.0)
Territory
Guam                           67.5 (61.4-73.0)      42.7 (36.9-48.8)

Abbreviations: CI = confidence interval; HHS = U.S. Department of
Health and Human Services; HPV = human papillomavirus; MenACWY =
quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps,
rubella vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid,
and acellular pertussis vaccine; UTD = up-to-date.

* Estimates for additional measures, including MMR, hepatitis B,
and varicella vaccines are available at
https://www.cdc.gov/vaccines/vaxview/teenvaxview.

([dagger]) Adolescents (N = 20,949) in the 2017 NIS-Teen were born
January 1999 through February 2005.

([section]) Estimates with 95% CIs >20 might be unreliable.

([paragraph]) [greater than or equal to] 1 dose Tdap vaccine at age
[greater than or equal to] 10 years.

** [greater than or equal to]1 dose of MenACWY or
meningococcal-unknown type vaccine.

([dagger][dagger]) HPV vaccine, nine-valent (9vHPV), quadrivalent
(4vHPV), or bivalent (2vHPV) in females and males combined.

([section][section]) HPV UTD includes those with [greater than or
equal to] 3 doses and those with 2 doses when the first HPV vaccine
dose was initiated before age 15 years and there was at least 5
months minus 4 days between the first and second dose. This update
to the HPV recommendation occurred in December of 2016.

([paragraph][paragraph]) Statistically significant (p<0.05)
percentage point increase compared to 2016.

*** The calculation for the range was limited to the 50 states and
the District of Columbia.

([dagger][dagger][dagger]) Statistically significant (p<0.05)
percentage point decrease from 2016.
COPYRIGHT 2018 U.S. Government Printing Office
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2018 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Walker, Tanja Y.; Elam-Evans, Laurie D.; Yankey, David; Markowitz, Lauri E.; Williams, Charnetta L.;
Publication:Morbidity and Mortality Weekly Report
Geographic Code:1U7TX
Date:Aug 24, 2018
Words:9397
Previous Article:Number of Youths Aged 2-19 Years and Adults Aged [greater than or equal to] 20 Years with Obesity or Severe Obesity--National Health and Nutrition...
Next Article:Trends in Human Papillomavirus-Associated Cancers--United States, 1999-2015.
Topics:

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters