1. Christina Dorell, MD, MPH
Human Papillomavirus (HPV) Vaccination Coverage in the United States, National Immunization Survey-Teen,
Christina Dorell, MD, MPH
Medical Epidemiologist
Immunization Services Division
2012 National Immunization Conference Online
March 26, 2012
National Center for Immunization & Respiratory Diseases

2. Christina Dorell
Has documented that she has no financial relationships to disclose or conflicts of interest to resolve.

3. Background
Since 2006, routine vaccination with the quadrivalent human papillomavirus (HPV) vaccine has been recommended for females 11 or 12 years with catch-up vaccination for females years. Since 2009, the bivalent HPV vaccine could also be given.

4. Background
In 2009, quadrivalent HPV vaccination of males years of age could be given if desired. In late 2011, routine HPV vaccination was recommended for all males 11 or 12 years with catch-up vaccination for males ages years. Males ages years may also be vaccinated if desired.

5. National Immunization Survey-Teen
NIS-Teen
Conducted since 2006
Random-digit-dialing household survey of parents of adolescents years
Provider-reported vaccination history
NIS-Teen represents a stratified national probability sample of U.S. households
More information on the NIS-Teen available at:

6. HPV vaccination coverage among females,13-17 Years, NIS-Teen, 2010
48.7% initiated the HPV series
32.0% received 3 doses
69.6% completion rate (those who initiated the series and had enough time to finish received 3 doses)
94.3% who initiated the series had enough time to finish it before the interview (≥24 weeks)

7. HPV vaccination coverage among males,13-17 Years, NIS-Teen, 2010
1.4% initiated the HPV series
0.1% received 3 doses
41.6% completion rate (those who initiated the series and had enough time to finish received 3 doses)
12.7% who initiated the series had enough time to finish it before the interview (≥24 weeks)

8. HPV vaccination estimates among females, 13-17 years, NIS-Teen, United States, 2007-2010

9. Tdap,* MCV4,† and HPV§ vaccination estimates among adolescents, years, NIS-Teen, United States,
≥1 Tdap
↑13.3
≥1 MCV4
↑14.8
↑9.1
≥1 HPV
↑9.8
↑4.4
↑7.1
≥3 HPV
↑5.3
↑8.8
* Tetanus toxoid, diphtheria toxoid, acellular pertussis vaccine
† Meningococcal conjugate vaccine
§ Among females

10. HPV vaccination estimates among females, 13-17 Years, NIS-Teen, United States 2010
In 2010, state coverage ranged from 28.8% (ID) to 73.0% (RI). The darkest shades of pink represent coverage of 60% or more while the palest shades represent coverage of 29% or less.
[States with coverage >60% were RI, WA, SD, MA, DE, HI.
States with coverage<40% were IL, UT, AR, IN, NJ, MS, TN, ID.]

11. HPV vaccination series initiation and completion, 2008-2009: Objective
To describe factors associated with HPV vaccination series initiation (≥1 dose) and completion (≥3 doses) and parental intent to have their daughters vaccinated.
To describe reasons for not receiving the HPV vaccine
Dorell C, Yankey D, Santibanez T, Markowitz L. Human Papillomavirus Vaccination Series Initiation and Completion, Pediatrics.128:

12. HPV vaccination series initiation and completion, 2008-2009: Methods
2008 and 2009 NIS-Teen data were used
Provider-reported HPV vaccination coverage estimates are reported
Series completion was determined among females who received one HPV dose at least 24 weeks before the interview date
We performed logistic regression to identify factors associated with HPV series initiation and completion.

13. HPV vaccination series initiation and completion, 2008-2009: Results
National estimates
Initiation was 40.5%
Completion was 64.0%
HPV series initiation and completion rates were significantly higher in 2009 compared to 2008

14. HPV vaccination series initiation and completion, 2008-2009: Results
* Referent level
† NH – non-Hispanic
§ AI/AN – American Indian/Alaskan Native
Blue star signifies statistically significant difference in initiation rates after adjusting in multivariable analysis.
Red star signifies statistically significant difference in completion rates after adjusting in multivariable analysis.

15. HPV vaccination series initiation and completion, 2008-2009: Results
*Referent level
† Federal Poverty Level
§ Vaccines for Children Program
¶ State Children’s Health Insurance Program
Blue star signifies statistically significant difference in initiation rates after adjusting in multivariable analysis.
Red star signifies statistically significant difference in completion rates after adjusting in multivariable analysis.

16. HPV vaccination series initiation and completion, 2008-2009: Results
Referent level.
Blue star signifies statistically significant difference in initiation rates after adjusting in multivariable analysis.
Red star signifies statistically significant difference in completion rates after adjusting in multivariable analysis.

17. HPV vaccination series initiation and completion, 2008-2009: Unadjusted Results
Referent level
Blue star signifies statistically significant difference in initiation rates after adjusting in multivariable analysis.
Red star signifies statistically significant difference in completion rates after adjusting in multivariable analysis.

18. HPV vaccination series initiation and completion, 2008-2009: Unadjusted Results
Referent level.
Blue star signifies statistically significant difference in initiation rates after adjusting in multivariable analysis.
Red star signifies statistically significant difference in completion rates after adjusting in multivariable analysis.

19. HPV vaccination series initiation and completion, 2008-2009: Unadjusted Results
Referent level.
Blue star signifies statistically significant difference in initiation rates after adjusting in multivariable analysis.
Red star signifies statistically significant difference in completion rates after adjusting in multivariable analysis.

20. Intent to receive HPV vaccine within the next 12 months among unvaccinated females, years, by receipt of a provider recommendation, NIS-Teen, United States,

21. Main parent-reported reasons for intent not to receive the HPV vaccine within the next 12 months among females, years, NIS-Teen, United States,
Reasons for not intending to receive the HPV vaccine
% (95% CI)
Lack of knowledge
19.4 ( )
Not needed or not necessary
18.8 ( )
Not sexually active
18.3 ( )
Did not receive provider recommendation
13.1 ( )
Not appropriate age
7.3 ( )
Safety concern/side effects
7.3 ( )
More information /new vaccine
4.2 ( )

22. Major Findings
Compared to the rate of increase in vaccination rates for other adolescent vaccines, increases in HPV vaccination uptake are smaller and slowing down.
Wide variation in vaccination rates by state.
≥1 Tdap
≥1 MCV4
≥1 HPV
≥3 HPV

23. Major Findings - Initiation
During , 40.5% of females received ≥1 HPV dose
Provider recommendation was strongly associated with initiation of the HPV series.
Parents who reported receiving a provider recommendation were more likely to intend to have their daughters vaccinated.

24. Major Findings - Initiation
Age
Girls ≥15 years were more likely to have initiated HPV series
11-12 year preventive check
Those who had a check-up were more likely to initiate
Health insurance status
Females who VFC-eligible and insured or had SCHIP were more likely to be vaccinated than privately insured females.
Uninsured VFC-eligible females were less likely to be vaccinated.
Facility Type
Girls who received all vaccinations in public facilities were less likely to initiate

25. Major Findings - Completion
Completion of the HPV series were low at 64.0% in
Lower completion among:
all races/ethnicities other than white
lower household incomes
VFC-eligible insured and uninsured
when all vaccination received at public facilities

26. Major Findings – Reasons for not vaccinating
Approximately 49% of parents of unvaccinated girls reported intentions to have their daughters vaccinated within the next 12 months.
Main parental reasons for non-intent to have their daughters vaccinated
Lack of knowledge about the vaccine
Vaccine is not needed
Daughter is not sexually active

27. Recommendations
Strong provider recommendations for HPV vaccination to their patients and parents are needed to improve vaccine uptake.
Provider education on disease risk, benefits of HPV vaccination, and addressing vaccine delay or refusal is needed to promote vaccine uptake at the recommended age.
Parental education on disease risk and benefits of HPV vaccination is needed to promote vaccine uptake at the recommended age.

28. Recommendations
Enhanced efforts to increase HPV initiation and completion among racial/ethnic minorities is needed.
Increasing access to health insurance, a usual source of care, and knowledge of and linkage to VFC should help improve vaccination rates among the uninsured.
Improved reminder-recall is needed among the VFC-eligible and those who receive vaccination in public facilities.

29. Recommendations
Increasing private insurance coverage of HPV vaccination and its administrative costs may improve uptake among the privately insured.*
Participating in registries and implementing reminder-recall systems to remind parents, patients, and vaccination providers when HPV doses are due will likely increase HPV completion rates.†
Improve understanding of the role state characteristics and vaccination funding policies and legislation play in HPV vaccination rates.
* Guide to Community Preventive Services. Universally recommended vaccinations: reducing client out-of-pocket costs for vaccinations (abbreviated). Last updated: 1/31/2011.
† Guide to Community Preventive Services. Universally recommended vaccinations: immunization information systems and : client reminder & recall systems . Last updated: 1/31/2011.

30. Thank you
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Web:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Immunization & Respiratory Diseases

31. Additional slides

32. HPV vaccination estimates among females ages 13-17 Years, NIS-Teen, United States 2010

33. HPV vaccination estimates among females ages 13-17 Years, NIS-Teen, United States 2010

34. HPV Vaccination Series Initiation and Completion, 2008-2009: Methods
Variables
Year and state
Metropolitan Statistical Area
Adolescent’s age
11-12 year preventive care visit
Race/ethnicity
Health Insurance status
Household income level
Parental knowledge of HPV disease
Mother’s education
Parental awareness of HPV vaccine
Mother’s marital status
Received a provider recommendation for vaccine
Mother’s age
Facility types where adolescent’s received vaccinations

35. HPV vaccination series initiation and completion, 2008-2009: Methods
All sociodemographic factors included in the bivariate analysis, as well as year of survey, and state of residence were included in the multivariable model.
SAS-callable SUDAAN 9.2
Differences in coverage were considered statistically significant at p≤0.05.

36. HPV Vaccination Series Initiation and Completion, 2008-2009: Results
Sample size: 18,228 girls
2008
30,725 completed household interviews
58.7% CASRO response rate
58.1% with adequate provider data
2009
34,976 completed household interviews
58.0% CASRO response rate
57.4% with adequate provider data

37. Main Parent-reported Reasons for Females, years, for Intent not to Receive the HPV Vaccine Within the Next 12 Months
Reasons for not intending to receive the HPV vaccine
% (95% CI)
Family/parental decision
3.9 ( )
Already up-to-date
3.3 ( )
Costs
3.2 ( )
Child should make decision
1.3 ( )
Child fearful
1.2 ( )
No doctor or doctor's visit not scheduled
1.1 ( )
Other
1.1 ( )
Handicapped/Special Needs/Illness
1.0 ( )

38. Adherence to recommended dosing intervals among females, years, who received at least 2 HPV doses, NIS-Teen, United States, a
a One month is considered 30.5 days.
b Among females who received at least two doses (n=6091).
c Among females who received at least three doses (n=4369).
Dorell C, Stokley S, Yankey D, Markowitz L. Compliance with recommended dosing intervals for HPV vaccination among females, years, National Immunization Survey-Teen, Vaccine. 30(3):

39. Adherence to recommended dosing intervals among females, years, who received at least 2 HPV doses, NIS-Teen,
Dosing interval
Definition of adherence (months)
Percent of participants (confidence interval)
Early
On time
Late
Doses 1-2b
1-3c
0.1 ( )
63.4 ( )
36.6 ( )
Doses 2-3d
3-5e
2.5 ( )
67.5 ( )
30.0 ( )
Doses 1-3d
6-7f
4.8 ( )
48.8 ( )
46.4 ( )
a One month is considered 30.5 days.
b Among females who received at least two doses (n=6091).
c ACIP recommendations are to receive the second dose 1-2 months after the first dose.
d Among females who received at least three doses (n=4369).
e ACIP recommendations are to receive the third dose 4 months after the second dose (minimum of 12 weeks).
f ACIP recommendations are to receive the third dose 6 months after the first dose (minimum 24 weeks).