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. Author manuscript; available in PMC: 2024 Mar 24.
Published in final edited form as: Pediatrics. 2022 Jul 1;150(1):e2022056597. doi: 10.1542/peds.2022-056597

Human Papillomavirus Vaccination Trends Among Adolescents: 2015 to 2020

Peng–jun Lu a, David Yankey a, Benjamin Fredu a, Mei–Chun Hung a, Natalie Sterrett a, Lauri E Markowitz b, Laurie D Elam–Evans a
PMCID: PMC10961167  NIHMSID: NIHMS1973476  PMID: 35730334

Abstract

OBJECTIVE:

To assess trends in recent human papillomavirus (HPV) vaccination initiation and factors associated with vaccination among adolescents.

METHODS:

The 2015 to 2020 National Immunization Survey–Teen data were used to assess vaccination trends. Multivariable logistic regression analysis were conducted to assess factors associated with vaccination.

RESULTS:

Overall, HPV vaccination coverage (≥1 dose) among adolescents significantly increased from 56.1% in 2015 to 75.4% in 2020. There were larger increases in coverage among males (4.7 percentage points annually) than females (2.7 percentage points annually) and coverage differences between males and females decreased in 2015 through 2020. Coverage in 2020 was 75.4% for adolescents aged 13 to 17 years; 73.7% for males and 76.8% for females (P < .05); 80.7% for those with a provider recommendation and 51.7% for those without (P < .05); and 80.3% for those with a well child visit at age 11 to 12 years, and 64.8% for those without (P < .05). Multivariable logistic regression results showed that main characteristics independently associated with a higher likelihood of vaccination included: a provider recommendation, age 16 to 17 years, non-Hispanic Black, Hispanic, or American Indian or Alaskan Native, Medicaid insurance, ≥2 provider contacts in the past 12 months, a well–child visit at age 11 to 12 years and having 1 or 2 vaccine providers (P < .05).

CONCLUSIONS:

Overall, HPV vaccination coverage among adolescents increased during 2015 to 2020. Coverage increased faster among males than females and differences by sex narrowed during this time. Receiving a provider recommendation vaccination was important to increase vaccination coverage.

Human papillomavirus (HPV) is the most common sexually transmitted infection in men and women in the United States.1 Vaccination is an important tool to prevent and control HPV infection and associated outcomes, including genital warts, precancerous lesions, and cancers, such as cervical, vaginal, vulvar, anal, penile, and oropharyngeal cancers.2–6 Since 2006, routine HPV vaccination of females aged 11 or 12 years (vaccine can be administered as young as age 9 years), as well as those aged 13 through 26 years not previously vaccinated, has been recommended by the Advisory Committee on Immunization Practices (ACIP).2 In 2011, ACIP recommended routine vaccination of males aged 11 to 12 years and those aged 13 to 21 years not previously vaccinated; recommendations stated that males aged 22 to 26 years may be vaccinated.3 Initially, ACIP recommended a 3-dose schedule for HPV vaccine. However, in 2016, this recommendation was revised to allow a 2-dose schedule (with an interval of at least 5 months between doses) if the vaccination series is initiated before the 15th birthday.5 In 2019, recommendations for catch-up HPV vaccination were harmonized across genders through age 26 years.6

HPV vaccination coverage among adolescents has been reported previously.7,8 The purpose of this study is to assess trends in recent HPV vaccination coverage and factors associated with vaccination among adolescents aged 13 to 17 years using data from the 2015 to 2020 National Immunization Survey–Teen (NIS–Teen). We could not provide HPV vaccination coverage on a wider age range since NIS-Teen is designed to assess vaccination coverage among adolescents aged 13 to 17 years.

METHODS

NIS–Teen is a national, random–digit–dial (RDD) telephone survey conducted by the Centers for Disease Control and Prevention (CDC). Survey data are collected in 2 phases. In the first phase, an RDD telephone interview is conducted to identify households with age–eligible adolescents (aged 13 to 17 years at the time of interview) and to collect demographic information from the parent or guardian on adolescent, maternal, and household characteristics. The interview also includes questions about the adolescent’s reported vaccination history. After completing the interview, parents or guardians are asked for consent to contact the adolescent’s vaccination provider(s). If consent is obtained, the adolescent’s vaccination providers are mailed a questionnaire to collect provider–reported vaccination histories for each recommended adolescent vaccine and selected childhood vaccines. The provider reported histories are used for determining vaccination coverage estimates.7–10 Beginning in 2018, the NIS–Teen used a single-frame sample of cell phone numbers. The landline telephone sample frame that was used from 2006 through 2017 was discontinued because of the declining number of landline-only households in the United States.11

NIS-Teen data from 2015 through 2020 were used to assess HPV vaccination coverage by year based on provider report. SUDAAN 11.0.1 was used to calculate point estimates and 95% confidence intervals (CIs). All analyses account for the complex sampling design of the NIS–Teen.9,10 T–tests were used to conduct trend analysis and comparison tests with the significance level set at P < .05. Multivariable logistic regression and predictive marginal modeling were conducted to derive the adjusted vaccination coverage estimates and adjusted prevalence ratios using the 2020 NIS–Teen. The NIS–Teen was approved by the CDC, National Center for Health Statistics Research Ethics Review Board and the National Opinion Research Center at the University of Chicago Institutional Review Board.

RESULTS

The Council of American Survey Research Organizations (CASRO) response rate for the 2020 NIS–Teen was 20.7%, and 45.2% of adolescents with completed interviews had adequate provider data. Sample characteristics of the study population by demographic and access-to-care characteristics are shown in Table 1. During 2015 through 2020, the prevalence of receiving a provider recommendation for HPV vaccine among adolescents aged 13 to 17 years increased from 68.4% in 2015 to 81.5% in 2020. During 2015 through 2020, the prevalence of having a well-child visit at age 11 to 12 years ranged from 46.3% to 50.4%, and the proportion of adolescents living in non-metropolitan statistical area (MSA) areas ranged from 10.7% to 13.0% among adolescents aged 13 to 17 years (Table 1).

TABLE 1.

Sample Characteristics of Adolescents Aged 13 to 17 Years in the United States, by Demographic and Access-to-Care Variables, NIS-Teen, 2015 to 2020

Survey Year
2015 2016 2017 2018 2019 2020
Subgroup and Age Group, y Sample Weighted % Sample Weighted % Sample Weighted % Sample Weighted % Sample Weighted % Sample Weighted %
Total 21 875 100 20 475 100 20 949 100 18 700 100 18 788 100 17 970 100
Parental report of provider recommendation for HPV vaccine
 Yes 13 964 68.4 (67.1–69.6) 13 733 71.4 (70.2–72.7) 14906 75.3 (74.1–76.5) 13 559 77.5 (76.4–78.7) 14054 79.6 (78.2–80.9) 13 786 81.5 (80.4–82.7)
 No 5935 31.6 (30.4–32.9) 4908 28.6 (27.3–29.8) 4294 24.7 (23.5–25.9) 3693 22.5 (21.3–23.6) 3280 20.4 (19.1–21.8) 2747 18.5 (17.3–19.6)
Age, y
 13–15 13 488 60.7 (59.4–61.9) 12 578 60.5 (59.2–61.7) 12 924 60.7 (59.5–62.0) 11 468 60.5 (59.2–61.8) 11 687 61.2 (59.6–62.6) 11 071 60.6 (59.2–61.9)
 16–17 8387 39.3 (38.1–40.6) 7897 39.5 (38.3–40.8) 8025 39.3 (38.0–40.5) 7232 39.5 (38.2–40.8) 7101 38.8 (37.4–40.4) 6899 39.4 (38.1–40.8)
Sex
 Male 11 367 51.1 (49.8–52.4) 10814 51.1 (49.8–52.3) 11 104 51.0 (49.7–52.3) 9772 51.0 (49.7–52.4) 9872 51.0 (49.5–52.6) 9445 51.5 (50.1–52.9)
 Female 10 508 48.9 (47.6–50.2) 9661 48.9 (47.7–50.2) 9845 49.0 (47.7–50.3) 8928 49.0 (47.6–50.3) 8916 49.0 (47.4–50.5) 8525 48.5 (47.1–49.9)
Race or ethnicity
 Non-Hispanic White 12 835 53.5 (52.3–54.8) 12 883 52.7 (51.5–54.0) 13010 52.3 (51.1–53.6) 11 128 51.9 (50.6–53.2) 11 883 52.0 (50.5–53.5) 11 348 50.7 (49.4–52.0)
 Non-Hispanic Black 2228 14.0 (13.2–14.9) 1990 13.7 (12.9–14.6) 1743 13.8 (12.9–14.8) 1488 13.7 (12.7–14.7) 1367 13.7 (12.6–14.8) 1614 14.2 (13.2–15.2)
 Hispanic 4610 22.8 (21.6–24.0) 3223 23.2 (22.0–24.5) 3882 23.7 (22.4–24.9) 4021 24.2 (23.0–25.4) 3466 24.7 (23.2–26.3) 3007 23.6 (22.3–25.0)
 American Indian or Alaskan Native 290 0.8 (0.7–1.0) 300 1.0 (0.8–1.2) 257 0.8 (0.6–1.1) 247 0.7 (0.6–0.9) 237 0.8 (0.6–1.0) 195 0.7 (0.6–1.0)
 Asian 751 4.0 (3.5–4.6) 862 4.2 (37–4.8) 818 4.4 (3.8–5.0) 601 4.0 (3.4–47) 607 3.6 (3.1–4.2) 689 4.8 (41–5.5)
 Other 1161 4.8 (4.3–5.3) 1217 5.1 (4.6–57) 1239 5.0 (4.6–5.5) 1215 5.5 (5.0–6.2) 1228 5.3 (47–5.9) 1117 6.0 (5.4–6.7)
Mother’s educational level
 <High school 2955 13.5 (12.5–14.5) 2205 13.4 (12.4–14.4) 2565 13.2 (12.3–14.1) 2368 12.3 (11.4–13.1) 1780 11.5 (10.6–12.5) 1516 12.3 (11.2–13.5)
 High school 3626 22.9 (21.7–24.1) 3253 22.4 (21.3–23.6) 3141 22.1 (21.0–23.3) 2929 21.9 (20.7–23.2) 2679 21.8 (20.4–23.3) 2700 20.9 (19.8–22.1)
 Some college or college graduate 5776 25.8 (24.7–26.9) 5369 25.0 (23.9–26.1) 5166 23.8 (22.7–24.9) 4721 24.2 (23.1–25.3) 4918 23.6 (22.3–24.9) 4570 24.3 (23.1–25.5)
 >College graduate 9518 37.9 (36.7–39.1) 9648 39.2 (38.0–40.4) 10 077 40.9 (39.7–42.1) 8682 41.7 (40.4–43.0) 9411 43.1 (41.6–44.6) 9184 42.5 (41.2–43.8)
Mother’s married status
 Married or living with partner 16 403 69.3 (68.1–70.5) 15 544 69.3 (68.1–70.5) 16 000 70.4 (69.2–71.7) 14095 70.0 (68.7–71.2) 14 327 70.2 (68.6–71.7) 13 528 70.3 (69.0–71.5)
 Widowed, divorced, or separated 3778 22.4 (21.3–23.5) 3448 22.0 (20.9–23.1) 3503 21.2 (20.1–22.3) 3257 21.1 (20.1–22.3) 3155 20.9 (19.6–22.4) 3058 20.6 (19.5–21.7)
 Never married 1475 8.3 (7.7–9.0) 1301 8.7 (8.0–9.5) 1240 8.4 (77–9.2) 1182 8.9 (8.1–9.8) 1139 8.9 (8.0–9.9) 1233 9.2 (8.4–10.0)
Mother’s age, y
 ≤34 1866 9.0 (8.3–9.8) 1686 8.9 (8.2–97) 1599 8.4 (77–9.2) 1407 7.9 (7.2–87) 1286 7.7 (6.9–8 6) 1187 7.3 (6.6–8.1)
 35–44 9241 44.2 (42.9–45.5) 8310 44.1 (42.8–45.4) 8447 42.8 (41.5–44.1) 7955 43.4 (42.1–44.7) 8097 44.7 (43.2–46.2) 7623 43.6 (42.2–44.9)
 ≥45 10 768 46.8 (45.5–48.0) 10 479 47.0 (45.7–48.3) 10 903 48.8 (47.6–50.1) 9338 48.7 (47.3–50.0) 9405 47.6 (46.1–49.1) 9160 49.2 (47.8–50.5)
Place of birth
 Born in United States 20 825 95.1 (94.5–95.6) 19 403 93.9 (93.2–94.6) 19 723 93.1 (92.3–93.9) 17 605 93.8 (93.1–94.5) 17 932 95.0 (94.3–95.7) 17111 94.9 (94.1–95.6)
 Born outside United States 891 4.9 (4.4–5.5) 948 6.1 (5.4–68) 1097 6.9 (6.1–77) 975 6.2 (5.5–6.9) 740 5.0 (4.3–57) 732 5.1 (44–5.9)
Income to poverty ratio
 <133% 6307 33.1 (31.8–34.4) 5103 31.7 (30.5–33.0) 5277 31.3 (30.1–32.5) 4860 29.1 (27.9–30.4) 4073 27.3 (25.9–28.8) 3741 27.2 (25.9–28.5)
 133% to <322% 5987 28.3 (27.2–29.5) 5787 28.8 (27.6–30.0) 5469 27.1 (25.9–28.2) 4976 27.2 (26.0–28.5) 5100 28.1 (26.7–29.6) 4846 28.9 (27.6–30.2)
 322% to <503% 4851 19.7 (18.8–20.7) 4121 17.6 (16.8–18.6) 4160 17.2 (16.3–18.1) 3614 18.3 (17.4–19.3) 3899 17.4 (16.4–18.4) 3836 18.4 (17.4–19.3)
 ≥503% 4730 18.9 (18.0–19.8) 5464 21.8 (20.8–22.8) 6043 24.4 (23.4–25.5) 5250 25.3 (24.2–26.5) 5716 27.2 (25.9–28.5) 5547 25.6 (24.5–26.7)
Medical insurancea
 Private only 12157 51.4 (50.1–52.7) 11 889 51.2 (49.9–52.5) 11 919 50.5 (49.2–51.8) 10315 52.1 (50.8–53.5) 11 183 54.3 (52.8–55.9) 10 764 53.5 (52.1–54.9)
 Any Medicaid 7010 36.5 (35.2–37.8) 6203 37.2 (35.9–38.5) 6504 37.5 (36.3–38.8) 5999 35.8 (34.5–37.2) 5366 34.5 (33.0–36.0) 5259 35.4 (34.0–36.8)
 Otherb 1800 7.7 (7.0–8.4) 1679 7.6 (7.0–8.2) 1708 7.6 (7.0–8.2) 1605 7.5 (6.9–8.1) 1545 7.1 16.4–7.8) 1343 6.8 16.2–7.5)
 Uninsured 908 4.4 (3.9–5.0) 702 4.1 13.5–4.7) 818 4.4 13.9–4.9) 781 4.5 (4.0–5.1) 694 4.1 13.6–4.7) 604 4.3 (3.7–5.0)
Provider contacts within past year
 None 2932 14.9 (14.0–15.9) 2608 14.9 (13.9–16.0) 2816 15.8 (14.8–16.8) 2402 14.6 (13.6–15.6) 2252 14.1 (13.0–15.3) 2433 16.7 (15.6–17.8)
 1 6119 30.0 (28.8–31.3) 5884 30.4 (29.2–31.6) 5798 29.7 (28.5–30.9) 5303 29.8 (28.5–31.1) 5281 29.9 (28.6–31.4) 5499 32.4 (31.1–33.7)
 2–3 7929 35.2 (34.0–36.4) 7385 35.3 (34.1–36.5) 7600 35.1 (33.9–36.3) 6724 35.8 (34.5–37.1) 6978 36.3 (34.9–37.8) 6443 34.1 (32.8–35.3)
 ≥4 4681 19.9 (18.9–20.9) 4392 19.4 (18.5–20.4) 4524 19.5 (18.5–20.4) 4085 19.9 (18.9–20.9) 4123 19.6 (18.5–20.8) 3447 16.9 (15.9–17.9)
Well child visit at age 11–12 yc
 Yes 10 472 47.1 (45.8–48.4) 9898 46.3 (45.1–47.6) 10 325 47.6 (46.3–48.9) 9260 48.5 (47.2–49.9) 9948 50.4 (48.9–51.9) 9016 49.9 (48.5–51.3)
 No 5341 22.8 (21.8–23.8) 4785 22.7 (21.7–23.8) 4733 21.6 (20.6–22.7) 4139 20.5 (19.5–21.6) 4053 21.1 (19.9–22.4) 3171 17.6 (16.6–18.7)
 Don’t know 6062 30.2 (29.0–31.4) 5792 30.9 (29.7–32.2) 5891 30.8 (29.6–32.0) 5301 30.9 (29.7–32.3) 4787 28.5 (27.0–29.9) 5783 32.5 (31.2–33.8)
Number of providers
 1 12138 58.2 (56.9–59.5) 11 760 59.2 (57.9–60.5) 12216 60.5 (59.2–61.7) 10 721 60.5 (59.2–61.8) 10 497 58.7 (57.2–60.2) 10 867 62.1 (60.7–63.4)
 2 6150 26.3 (25.2–27.5) 5578 26.2 (25.1–27.3) 5617 26.6 (25.4–27.8) 5098 26.4 (25.3–27.5) 5147 26.9 (25.5–28.3) 4777 26.0 (24.8–27.2)
 ≥3 3539 15.5 (14.6–16.4) 3061 14.6 (13.7–15.6) 3050 12.9 (12.1–13.8) 2817 13.1 (12.3–14.0) 3078 14.4 (13.5–15.4) 2277 12.0 (11.1–12.9)
MSA
 MSA principal city 9105 39.8 (38.6–41.0) 7979 40.1 (38.9–41.4) 8544 41.2 (40.0–42.5) 7564 42.4 (41.1–43.7) 7354 40.0 (38.5–41.5) 6927 40.6 (39.2–41.9)
 MSA non-principal city 8459 47.4 (46.1–48.6) 8248 46.9 (45.6–48.1) 8282 46.9 (45.7–48.2) 7543 46.9 (45.6–48.2) 7745 49.3 (47.8–50.8) 7720 48.7 (47.4–50.1)
 Non-MSA 4311 12.8 (12.2–13.5) 4248 13.0 (12.4–13.6) 4123 11.8 (11.2–12.4) 3593 10.7 (10.2–11.3) 3689 10.7 (10.0–11.3) 3323 10.7 (10.1–11.3)
Region
 Northeast 4049 16.6 (16.2–17.1) 4049 16.5 (16.0–16.9) 3975 16.4 (15.9–16.8) 3437 16.2 (15.6–16.8) 3597 16.0 (15.4–16.6) 4020 17.5 (17.0–18.1)
 Midwest 4666 21.6 (21.0–22.1) 4313 21.4 (20.9–22.0) 4485 21.3 (20.9–21.8) 4094 21.2 (20.7–21.8) 3985 21.2 (20.5–21.8) 4508 23.4 (22.8–24.1)
 South 8355 38.0 (37.3–38.8) 7620 38.3 (37.5–39.0) 8032 38.4 (37.6–39.2) 7184 38.6 (37.8–39.4) 7057 38.8 (37.8–39.8) 7189 43.2 (42.3–44.2)
 West 4805 23.8 (22.9–24.7) 4493 23.8 (23.0–24.7) 4457 23.9 (23.0–24.8) 3985 24.0 (23.0–25.0) 4149 24.1 (22.8–25.4) 2253 15.8 (14.9–16.8)
Facility type
 All private facilities 10 891 54.7 (53.5–56.0) 10146 53.0 (51.7–54.3) 10 337 52.5 (51.3–53.8) 9038 52.8 (51.5–54.2) 9257 53.4 (51.8–54.9) 8840 54.3 (53.0–55.7)
 All public facilities 3157 13.6 (12.8–14.5) 2925 14.5 (13.6–15.5) 3123 16.3 (15.3–17.3) 2724 15.2 (14.1–16.2) 2616 15.2 (14.0–16.5) 2392 13.7 (12.7–14.7)
 All hospital facilities 2311 9.1 18.5–9.8) 2426 10.1 (9.4–10.9) 2485 9.9 (9.2–10.6) 2267 10.2 (9.5–10.9) 2469 10.9 (10.0–11.8) 2742 12.4 (11.6–13.2)
 All sexually transmitted diseases, school, and teen clinics or other facilities 331 1.6 (1.3–2.0) 328 2.0 (1.6–2.5) 377 2.3 (1.8–2.8) 302 1.8 (1.5–2.2) 278 1.8 (1.3–2.4) 260 1.5 (1.2–1.9)
 Mixedd 4753 19.7 (18.7–20.7) 4209 19.0 (18.1–20.0) 4173 17.8 (16.9–18.8) 3974 18.8 (17.8–19.8) 3762 17.6 (16.5–18.8) 3410 17.1 (16.1–18.1)
 Othere 301 1.2 (1.0–1.5) 289 1.3 (1.1–1.6) 310 1.2 (1.0–1.4) 262 1.2 (1.0–1.5) 274 1.1 (0.9–1.4) 213 1.0 (0.8–1.3)
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a

Insurance categories are mutually exclusive.

b

Indian Health Service, Children’s Health Insurance Program, military, and some private.

c

Status of health-care visit at age 11 to 12 y based on provider reported data.

d

Mixed indicates that the facility is identified to be in more than 1 of the facility categories such as private, public, hospital, sexually transmitted diseases, school, or teen clinics.

e

Includes military, WIC clinics, and pharmacies.

Overall, HPV vaccination coverage (≥1 dose) among adolescents aged 13 to 17 years significantly increased from 56.1% in 2015 to 75.4% in 2020, with a total increase of 19.1 percentage points and an average increase of 3.8 percentage points annually (Table 2). HPV vaccination series completion coverage among adolescents aged 13 to 17 years significantly increased from 40.3% in 2015 to 59.3% in 2020, with a total increase of 18.4 percentage points and an average increase of 3.6 percentage points annually. From 2015 through 2020, HPV vaccination coverage among adolescents significantly increased across almost all levels of demographic and access-to-care characteristics (Table 2).

TABLE 2.

HPV Vaccination Coverage (≥1 Dose) of Adolescents Aged 13–17 Years in the United States, by Demographic, and Access-to-Care Variables, NIS–Teen, 2015 to 2020

Survey Year
2015 2016 2017 2018 2019 2020 Average Annual Change %
Subgroup and Age Group, y % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Total Change %
Total 56.1 (54.9 to 57.4) 60.4 (59.2 to 61.6)a 65.5 (64.3 to 66.7)a 68.1 (66.8 to 69.3)a 71.5 (70.1 to 72.8)a 75.4 (74.2 to 76.6)a 19.1 (17.4 to 20.8)b 3.8 (3.4 to 4.1)b
Parental report of provider recommendation for HPV vaccine
 Yes 69.3 (67.8 to 70.8)d 71.1 (69.7 to 72.4)d 73.2 (71.8 to 74.5)a,d 74.7 (73.3 to 76.0)d 77.5 (76.0 to 79.0)a,d 80.7 (79.6 to 81.9)a,d 11.4 (9.5 to 13.3)b 2.2 (1.9 to 2.6)b
 Noc 30.7 (28.5 to 33.0) 37.1 (34.5 to 39.8)a 44.1 (41.1 to 47.1 )a 46.7 (43.8 to 49.6) 49.1 (45.6 to 52.7) 51.7 (48.2 to 55.3) 21.0 (16.8 to 25.2)b 4.3 (3.5 to 5.1)b
Age, y
 13 to 15c 54.4 (52.7 to 56.1) 58.3 (56.7 to 59.9)a 64.1 (62.6 to 65.7)a 66.4 (64.8 to 68.0)a 71.0 (69.4 to 72.7)a 73.4 (71.8 to 74.9)a 19.0 (16.7 to 21,2)b 3.9 (3.5 to 4.3)b
 16–17 58.8 (56.8 to 60.7)d 63.6 (61.7 to 65.4)a,d 67.7 (65.8 to 69.5)a,d 70.7 (68.7 to 72.5)a,d 72.1 (69.8 to 74.3) 78.1 (76.4 to 79.8)a,d 19.3 (16.7 to 21,9)b 3.6 (3.1 to 4.1)b
Sex
 Malec 49.8 (48.0 to 51.6) 56.0 (54.3 to 57.7)a 62.6 (60.9 to 64.2)a 66.3 (64.6 to 68.0)a 69.8 (67.9 to 71.7)a 73.7 (72.1 to 75.4)a 24.0 (21.5 to 26.4)b 4.7 (4.3 to 5.2)b
 Female 62.8 (61.0 to 64.5)d 65.1 (63.3 to 66.8)d 68.6 (66.9 to 70.2)a,d 69.9 (68.1 to 71.6)d 73.2 (71.3 to 75.0)a,d 76.8 (75.2 to 78.4)a,d 14.0 (11.6 to 16.4)b 2.7 (2.3 to 3.2)b
Race or ethnicity
 Non-Hispanic Whitec 51.4 (49.9 to 52.9) 54.7 (53.2 to 56.1 )a 60.0 (58.6 to 61,5)a 63.5 (62.0 to 65.1 )a 68.3 (66.8 to 69.9)a 71.4 (69.9 to 72.8 a 19.9 (17.9 to 22.0)b 4.1 (3.8 to 4.5)b
 Non-Hispanic Black 60.1 (56.7 to 63.4)d 65.9 (62.5 to 69.1 )a,d 70.0 (66.4 to 73.3)d 72.8 (69.3 to 76.1 )d 72.0 (67.8 to 75.9) 78.3 (75.0 to 81.5)a,d 18.2 (13.5 to 22.9)b 3.2 (2.3 to 4.1)b
 Hispanic 63.6 (60.1 to 67.0)d 69.8 (66.6 to 72.7)a,d 74.5 (71.7 to 77.1 )a,d 75.5 (72.7 to 78.2)d 76.8 (73.3 to 79.9)d 80.7 (77.9 to 83.5)d 17.1 (12.6 to 21.5)b 3.1 (2.2 to 3.9)b
 American Indian or Alaskan Native 64.2 (55.0 to 72.5)d 62.3 (52.5 to 71.3) 60.2 (45.5 to 73.2) 70.1 (59.6 to 78.9) 71.1 (58.2 to 81.3) 85.6 (79.3 to 91.9)a,d 21.4 (10.5 to 32.2)b 3.9 (1.2 to 6.7)b
 Asian 56.6 (49.7 to 63.2) 62.5 (55.7 to 68.9)d 70.4 (64.5 to 75.7)d 65.3 (56.5 to 73.2) 74.8 (68.1 to 80.5) 75.8 (70.0 to 81.6) 19.2 (10.3 to 28.1)b 3.6 (1.9 to 5.3)b
 Other 60.2 (55.0 to 65.3)d 60.6 (55.2 to 65.7)d 64.9 (60.3 to 69.2)d 68.0 (63.0 to 72.6) 73.8 (68.7 to 78.4)d 77.6 (72.8 to 82.5)d 17.4 (10.3 to 24.5)b 3.7 (2.4 to 5.1)b
Mother’s educational level
 <High schoolc 69.0 (65.3 to 72.6) 71.9 (68.0 to 75.5) 74.6 (71.2 to 77.7) 77.6 (74.6 to 80.3) 78.0 (73.6 to 81.9) 84.2 (80.7 to 87.8)a 15.2 (10.1 to 20.3)b 2.8 (1.8 to 3.8)b
 High school 54.8 (51.8 to 57.8)d 62.2 (59.5 to 64.8)a,d 66.4 (63.6 to 69.0)a,d 67.9 (64.8 to 70.8)d 71.3 (67.8 to 74.5)d 73.1 (70.3 to 76.0)d 18.4 (14.2 to 22.5)b 3.5 (2.7 to 4.3)b
 Some college or college graduate 52.2 (49.7 to 54.6)d 56.2 (53.7 to 58.6)a,d 63.0 (60.5 to 65.4)a,d 65.1 (62.7 to 67.4)d 68.7 (65.9 to 71.4)d 71.8 (69.4 to 74.2)d 19.6 (16.2 to 23.1)b 4.0 (3.3 to 4.6)b
 >College graduate 55.1 (53.3 to 56.8)d 58.2 (56.4 to 59.9)a,d 63.6 (61.9 to 65.4)a,d 67.1 (65.2 to 69.0)a,d 71.3 (69.5 to 73.1 )a,d 75.6 (74.1 to 77.2)a,d 20.6 (18.2 to 22.9)b 4.2 (3.7 to 4.6)b
Mother’s married status
 Married or living with partnerc 54.6 (53.1 to 56.1) 58.8 (57.3 to 60.2)a 64.0 (62.5 to 65.3)a 66.5 (65.0 to 67.9)a 69.7 (68.2 to 71.2)a 74.0 (72.6 to 75.4)a 19.4 (17.4 to 21.4)b 3.8 (3.4 to 4.2)b
 Widowed, divorced, or separated 57.0 (54.0 to 60.0) 61.3 (58.4 to 64.1 )a 67.3 (64.6 to 70.0)a,d 69.7 (67.0 to 72.3)d 73.9 (70.4 to 77.1 )d 77.2 (74.7 to 79.7)d 20.3 (16.4 to 24.2)b 4.1 (3.2 to 4.9)b
 Never married 66.3 (62.4 to 70.1 )d 70.0 (65.8 to 73.8)d 73.7 (69.4 to 77.7)d 75.9 (71.1 to 80.1 )d 77.5 (72.3 to 82.0)d 80.0 (76.3 to 83.8)d 13.7 (8.3 to 19.1)b 2.7 (1.6 to 3.7)b
Mother’s age
 ≤34 yc 63.4 (59.2 to 67.5) 66.2 (62.0 to 70.1) 70.2 (66.1 to 74.0) 70.6 (65.9 to 74.8) 78.7 (74.6 to 82.3)a 73.3 (68.8 to 77.8) 9.9 (3.8 to 16.0)b 2.6 (1.5 to 3.7)b
 35–44 y 56.7 (54.7 to 58.7)d 59.7 (57.7 to 61,5)a,d 66.2 (64.3 to 68.1 )a 67.4 (65.6 to 69.2) 69.6 (67.4 to 71.7)d 75.1 (73.4 to 76.8)a 18.4 (15.8 to 21.0)b 3.5 (3.0 to 4.0)b
 ≥45 y 54.2 (52.4 to 55.9)d 60.0 (58.3 to 61,8)a,d 64.1 (62.5 to 65.8)a,d 68.3 (66.5 to 70.1 )a 72.1 (70.2 to 73.8)a,d 75.7 (74.0 to 77.4)a 21.5 (19.0 to 23.9)b 4.2 (3.8 to 4.7)b
Place of birth
 Born in United Statesc 55.9 (54.6 to 57.2) 60.0 (58.7 to 61,2)a 65.0 (63.8 to 66.2)a 67.7 (66.4 to 69.0)a 71.3 (69.9 to 72.6)a 75.0 (73.8 to 76.2)a 19.1 (17.4 to 20.9)b 3.8 (3.5 to 4.1)b
 Born outside United States 60.3 (54.3 to 66.0) 67.4 (61.3 to 73.0)d 73.1 (68.1 to 77.5)d 74.8 (69.9 to 79.2)d 75.7 (70.0 to 80.7) 79.7 (73.5 to 85.9) 19.4 (10.9 to 28.0)b 3.5 (1.9 to 5.1)b
Income to poverty ratio
 <133%c 63.2 (60.8 to 65.6) 67.7 (65.5 to 69.9)a 72.7 (70.5 to 74.7)a 74.7 (72.4 to 76.8) 76.2 (73.3 to 78.9) 81.2 (79.0 to 83.4)a 18.0 (14.7 to 21.2)b 3.4 (2.7 to 4.0)b
 133% to <322% 51.3 (48.9 to 53.7)d 56.6 (54.3 to 58.9)a,d 60.8 (58.5 to 63.1 )a,d 64.0 (61.5 to 66.4)d 67.7 (65.0 to 70.2)a,d 70.2 (67.7 to 72.7)d 18.9 (15.5 to 22.4)b 3.8 (3.1 to 4.4)b
 322% to <503% 51.4 (48.7 to 54.0)d 53.0 (50.2 to 55.8)d 61.1 (58.4 to 63.8)a,d 63.7 (60.9 to 66.4)d 67.7 (64.9 to 70.3)a,d 70.4 (67.9 to 72.8)d 19.0 (15.4 to 22.6)b 4.0 (3.34.7)b
 ≥503% 56.0 (53.4 to 58.5)d 60.8 (58.3 to 63.2)a,d 64.7 (62.3 to 67.0)a,d 68.1 (65.5 to 70.6)d 73.1 (70.6 to 75.5)a 78.1 (76.1 to 80.0)a,d 22.1 (18.9 to 25.3)b 4.3 (3.7–5.0)b
Medical insurancec
 Private onlyc 52.5 (50.9 to 054.1) 56.0 (54.4 to 57.6)a 62.5 (60.8 to 64.1 )a 65.4 (63.7 to 67.1 )a 70.6 (68.9 to 72.2)a 73.5 (71.9 to 75.0)a 21.0 (18.7 to 23.2)b 4.3 (3.9 to 4.8)b
 Any Medicaid 64.1 (61.8 to 66.3)d 68.0 (65.9 to 70.1 )a,d 71.3 (69.3 to 73.3)a,d 74.4 (72.3 to 76.3)a,d 75.0 (72.4 to 77.5)d 79.8 (77.9 to 81.8)a,d 15.8 (12.8 to 18.8)b 2.9 (2.4 to 3.5)b
 Othere,f 51.6 (47.1 to 56.1) 55.4 (51.4 to 59.4) 62.0 (57.8 to 65.9)a 63.7 (59.7 to 67.4) 67.4 (62.9 to 71.7) 71.3 (67.1 to 75.5) 19.7 (13.5 to 25.8)b 3.9 (2.7 to 5.1)b
 Uninsured 41.0 (34.8 to 47.5)d 55.5 (48.2 to 62.5)a 57.5 (51.8 to 62.9) 56.2 (50.1 to 62.2)d 60.3 (53.4 to 66.8)d 65.6 (58.4 to 72.7)d 24.6 (15.0 to 34.2)b 3.9 (2.2 to 5.7)b
Provider contacts within past year
 Nonec 46.8 (43.2 to 50.3) 52.9 (49.1 to 56.6)a 60.2 (56.8 to 63.5)a 58.7 (55.2 to 62.2) 62.9 (58.7 to 67.0) 69.2 (65.9 to 72.6)a 22.5 (17.6 to 27.4)b 4.0 (3.1 to 5.0)b
 1 53.7 (51.2 to 56.2)d 59.3 (57.0 to 61,6)a,d 64.7 (62.3 to 66.9)a,d 67.4 (65.0 to 69.6)d 70.9 (68.2 to 73.4)a,d 75.4 (73.3 to 77.6)a,d 21.7 (18.4 to 25.0)b 4.2 (3.5 to 4.8)b
 2–3 59.4 (57.4 to 61.3)d 63.2 (61.2 to 65.1 )a,d 67.5 (65.5 to 69.4)a,d 69.9 (67.8 to 71.9)d 73.7 (71.6 to 75.7)a,d 76.8 (75.0 to 78.7)a,d 17.4 (14.8 to 20.1 )b 3.5 (3.0 to 4.0)b
 ≥4 60.6 (57.9 to 63.1 )d 63.1 (60.5 to 65.6)d 67.1 (64.6 to 69.5)a,d 72.2 (69.4 to 74.7)a,d 73.0 (70.4 to 75.5)d 77.3 (74.8 to 79.7)a,d 16.7 (13.2 to 20.3)b 3.4 (2.7 to 4.1)b
Well child visit at age 11–12 yg
 Yes 61.6 (59.8 to 63.4)d 66.9 (65.3 to 68.5)a,d 71.7 (70.1 to 73.2)a,d 73.7 (72.0 to 75.3)d 78.0 (76.4 to 79.5)a,d 80.3 (78.8 to 81.8)a,d 18.7 (16.3 to 21,0)b 3.7 (3.2 to 4.1)b
 Noc 47.1 (44.6 to 49.6) 51.6 (48.9 to 54.3)a 55.8 (53.2 to 58.4)a 60.5 (57.8 to 63.2)a 61.8 (58.7 to 64.8) 64.8 (61.8 to 67.9) 17.8 (13.8 to 21,7)b 3.6 (2.9 to 4.3)b
 Don’t know 54.4 (51.9 to 56.8)d 57.2 (54.8 to 59.5)d 62.8 (60.5 to 65.1 )a,d 64.4 (61.9 to 66.8)d 67.1 (64.0 to 70.1 )d 73.0 (70.9 to 75.1 )a,d 18.7 (15.4 to 21,9)b 3.6 (3.0 to 4.2)b
Number of providers
 1 56.6 (55.0 to 58.3) 63.1 (61.6 to 64.7)a,d 67.4 (65.9 to 68.9)a,d 70.1 (68.4 to 71.7)a,d 74.3 (72.6 to 76.0)a,d 76.7 (75.2 to 78.1 )a,d 20.0 (17.8 to 22.2)b 3.9 (3.5 to 4.3)b
 2 56.7 (54.2 to 59.2) 57.5 (55.2 to 59.8) 63.3 (60.8 to 65.6)a 66.7 (64.4 to 68.9)a,d 68.0 (65.3 to 70.6) 75.5 (73.3 to 77.6)a,d 18.7 (15.5 to 22.0)b 3.6 (3.0 to 4.3)b
 ≥3c 53.6 (50.3 to 56.9) 55.3 (51.7 to 58.8) 61.9 (58.7 to 65.1 )a 62.3 (58.9 to 65.6) 67.2 (63.8 to 70.4)a 68.5 (64.7 to 72.4) 14.9 (9.8 to 20.0)b 3.2 (2.3 to 4.1)b
MSA
 MSA principal cityc 62.2 (60.1 to 64.2) 65.9 (64.0 to 67.9)a 70.1 (68.2 to 71,9)a 71.9 (69.8 to 73.9) 73.8 (71.5 to 75.9) 77.8 (75.9 to 79.7)a 15.6 (12.8 to 18.4)b 2.9 (2.4 to 3.5)b
 MSA nonprincipal city 53.3 (51.4 to 55.2)d 58.5 (56.6 to 60.3)a,d 63.1 (61.3 to 64.8)a,d 66.6 (64.8 to 68.4)a,d 71.2 (69.2 to 73.1 )a 74.7 (73.0 to 76.3)a,d 21.4 (18.9 to 23.9)b 4.2 (3.8 to 4.7)b
 Non–MSA 47.8 (45.2 to 50.4)d 50.4 (47.8 to 53.0)d 59.3 (56.6 to 61,9)a,d 59.5 (56.8 to 62.2)d 64.2 (61.2 to 67.2)a,d 68.0 (65.2 to 70.8)d 20.2 (16.4 to 24.0)b 4.1 (3.4 to 4.8)b
Region
 Northeast 62.6 (60.2 to 64.9) 67.3 (65.0 to 69.5)a 70.3 (68.1 to 72.5) 71.1 (68.4 to 73.7) 74.1 (71.5 to 76.6) 79.4 (77.3 to 81 5)a 16.8 (13.7 to 20.0)b 3.0 (2.4 to 3.6)b
 Midwest 54.0 (51.9 to 56.0)d 57.9 (55.7 to 60.0)a,d 64.7 (62.8 to 66.6)a,d 69.3 (67.3 to 71.2)a 71.3 (69.2 to 73.2) 75.5 (73.7 to 77.4)a 21.6 (18.8 to 24.3)b 4.4 (3.8 to 4.9)b
 South 52.1 (50.2 to 53.9)d 54.8 (53.0 to 56.6)a,d 61.4 (59.7 to 63.2)a,d 63.8 (62.0 to 65.6)d 68.0 (66.1 to 69.9)a,d 72.3 (70.5 to 74.2)a,d 20.3 (17.7 to 22.8)b 4.1 (3.6 to 4.6)b
 Westc 60.1 (56.4 to 63.7) 67.0 (63.6 to 70.2)a 69.5 (66.1 to 72.7) 71.9 (68.3 to 75.2) 75.5 (71.5 to 79.1) 78.1 (74.2 to 82.0) 18.0 (12.7 to 23.3)b 3.4 (2.4 to 4.4)b
Facility type
 All private facilitiesc 55.9 (54.1 to 57.7) 60.7 (59.0 to 62.4)a 65.6 (63.9 to 67.2)a 68.4 (66.6 to 70.1 )a 72.2 (70.3 to 73.9)a 76.5 (75.0 to 78.0)a 20.6 (18.2 to 22.9)b 4.0 (3.5 to 4.5)b
 All public facilities 55.4 (52.1 to 58.7) 61.1 (57.9 to 64.2)a 64.9 (61.6 to 68.0) 67.2 (63.7 to 70.6) 69.7 (65.6 to 73.5) 73.5 (69.9 to 77.1) 18.0 (13.1 to 22.9)b 3.4 (2.5 to 4.3)b
 All hospital facilities 59.2 (55.5 to 62.7) 66.3 (62.8 to 69.6)a,d 67.9 (64.3 to 71.4) 70.6 (67.1 to 74.0) 74.4 (70.9 to 77.5) 75.7 (72.7 to 78.6) 16.5 (11.8 to 21.1 )b 3.1 (2.2 to 3.9)b
 All sexually transmitted diseases, school, and teen clinics or other facilities 49.6 (37.7 to 61.5) 59.2 (47.1 to 70.3) 63.9 (54.3 to 72.6) 70.1 (61.2 to 77.8) 72.3 (60.9 to 81.3) 70.2 (59.4 to 80.9) 20.6 (4.4 to 36.8)b 4.3 (1.0 to 7.7)b
 Mixede,h 58.0 (55.2 to 60.7) 58.6 (55.8 to 61.3) 66.9 (64.3 to 69.4)a 69.8 (67.2 to 72.3) 71.8 (68.6 to 74.7) 76.4 (73.6 to 79.2)a 18.5 (14.5 to 22.4)b 3.9 (3.1 to 4.6)b
 Otherc 42.9 (33.1 to 53.2)d 43.6 (33.2 to 54.5)d 52.0 (43.1 to 60.8)d 33.9 (25.1 to 44.0)a,d 49.5 (38.8 to 60.4)a,d 38.1 (27.0 to 49.2)d −4.7 (−19.8 to 10.3) −0.6 (−3.2–2.0)
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CI, confidence interval.

a

P < .05 for comparison with the previous year (t test for comparison between 2 y, with the prior year as the reference group- for example, 2016 vs 2015, 2017 vs 2016, 2018 vs 2017, 2019 vs 2018, and 2020 vs 2019).

b

P < .05 for overall trend (Linear trend test for trend from 2015 through 2020).

c

Reference level.

d

P < .05 compared with reference for each year within each variable.

e

Insurance categories are mutually exclusive.

f

Children’s Health Insurance Program, Indian Health Service, military, and some private.

g

Status of health-care visit at age 11–12 y based on provider reported data.

h

Mixed indicates that the facility is identified to be in more than one of the facility categories such as private, public, hospital, STD, school, and teen clinics.

i

Includes military, WIC clinics, and pharmacies.

Vaccination coverage among adolescents aged 16 to 17 years (range:58.8% in 2015 to 78.1% in 2020) was significantly higher than those aged 13 to 15 years in all survey years assessed (P < .05) except 2019 (P > .05) (range:54.4% in 2015 to 73.4% in 2020) (P < .05) (Table 2). Vaccination coverage among female adolescents (range:62.8% in 2015 to 76.8% in 2020) was significantly higher than male adolescents in all survey years assessed (range:49.8% in 2015 to 73.7% in 2020) (P < .05) (Table 2, Fig 1). Overall, HPV vaccination coverage (≥1 dose) among male adolescents aged 13 to 17 years significantly increased from 2015 to 2020, with a total increase of 24.0 percentage points and an average increase of 4.7 percentage points annually (Table 2, Fig 1). Overall, HPV vaccination coverage (≥1 dose) among female adolescents aged 13 to 17 years significantly increased from 2015 to 2020, with a total increase of 14.0 percentage points and an average increase of 2.7 percentage points annually (Table 2, Fig). Coverage increased faster among males than females and difference between males and females narrowed during this time. Vaccination coverage among non-Hispanic Black (range: 60.1% in 2015 to 78.3% in 2020) and Hispanic adolescents (range: 63.6% in 2015 to 80.7% in 2020) was significantly higher than non-Hispanic White adolescents in all years assessed (P < .05) except 2019, where coverage among non-Hispanic Black adolescents was not higher than coverage among non-Hispanic White adolescents (P > .05) (range: 51.4% in 2015 to 71.4% in 2020) (P < .05) (Table 2).

FIGURE 1.

FIGURE 1

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HPV vaccination coverage (≥1 dose) among adolescents 13 to 17 years, United States, 2015 to 2020. Source: national immunization survey teen, 2015 to 2020. Males, females, males with provider recommendation, males without provider recommendation, females with provider recommendation, and females without provider recommendation.

HPV vaccination coverage among adolescents aged 13 to 17 years with a reported provider recommendation significantly increased from 69.3% in 2015 to 80.7% in 2020 (test for trend, P <), and vaccination coverage of adolescents with a provider recommendation was consistently and significantly higher than those without a provider recommendation in all years assessed (range: 30.7% in 2015 to 51.7% in 2020) (P < .05) (Table 2). HPV vaccination coverage among male adolescents aged 13 to 17 years with a provider recommendation significantly increased from 67.5% in 2015 to 79.7% in 2020 (test for trend, P < .05), and vaccination coverage of male adolescents with a provider recommendation was consistently and significantly higher than those without a provider recommendation in all years assessed (range: 25.4% in 2015 to 52.4% in 2019) (P < .05) (Fig 1). HPV vaccination coverage among female adolescents aged 13 to 17 years with a provider recommendation significantly increased from 70.8% in 2015 to 81.8% in 2020 (test for trend, P < .05), and vaccination coverage of female adolescents with a provider recommendation was consistently and significantly higher than those without a provider recommendation in all years assessed (range: 39.8% in 2016 to 53.5% in 2020) (P < .05) (Fig 1). HPV vaccination coverage among adolescents aged 13 to 17 years with a well–child visit at age 11 to 12 years significantly increased from 61.6% in 2015 to 80.3% in 2020 (test for trend, P < .05), and vaccination coverage of adolescents with a well–child visit at age 11 to 12 years was consistently and significantly higher than those without a well–child visit at age 11 to 12 years over all years assessed (range: 47.1% in 2015 to 64.8% in 2020) (P < .05) (Table 2). Vaccination coverage among adolescents with 1 or more provider contacts within the past year was significantly higher than those without a provider contact within the past year in all years assessed (P < .05).

Additionally, vaccination coverage among adolescents with a mother who had equal to or more than a high school education was significantly lower than those with less than high school education in all years assessed (P < .05) (Table 2). Coverage among adolescents living in non-MSA areas was significantly lower than those living in MSA principal cities in all years assessed (P < .05) (Table 2).

In multivariable analyses of 2020 data, characteristics independently associated with a higher likelihood of HPV vaccination included: receiving a provider recommendation, being age 16 to 17 years, being of non-Hispanic Black, Hispanic, or American Indian or Alaskan Native (AIAN) adolescents (reference: non-Hispanic White adolescents), having a mother who is widowed, divorced, or separated (reference: married), having Medicaid insurance (reference: private insurance), having ≥2 provider contacts in the past 12 months (reference: without a provider contact), having a well–child visit at age 11 to 12 years (reference: without a well–child visit), and having 1 or 2 vaccination providers (reference: ≥3 vaccination provider) (P < .05). Participants having a mother with high school, some college or college graduate (reference: <high school), those with an income to poverty ratio between 133% and 503% (reference: <133%) and those living in non-MSA – more rural MSAs (reference: MSA principal city) had a lower likelihood of HPV vaccination (P < .05) (Table 3).

TABLE 3.

Multivariable Logistic Regression and Predictive Marginal Analysis of HPV Vaccination (≥1 Dose) of Adolescents Aged 13 to 17 Years in the United States, by Demographic and Access-to-Care Variables, NIS–Teen, 2020

Characteristic Adjusted Coverage % (95% CI) Adjusted Prevalence Ratio % (95% CI)
Parental report of provider recommendation for vaccine
 Yes 64.4 (62.9–65.9) 1.52 (1.41–1.62)a
 Nob 35.8 (32.6–39.0) ref.
Age, y
 13–15b 55.5 (53.7–57.3) ref.
 16–17 65.3 (63.3–67.3) 1.05 (1.02–1.09)a
Sex
 Maleb 57.4 (55.5–59.3) ref.
 Female 61.3 (59.5–63.2) 1.02 (0.99–1.05)
Race and ethnicity
 Non–Hispanic Whiteb 55.6 (53.8–57.4) ref.
 Non–Hispanic Black 63.2 (59.3–67.0) 1.10 (1.05–1.15)a
 Hispanic 65.6 (62.4–68.8) 1.11 (1.07–1.16)a
 American Indian or Alaskan Native 74.6 (66.6–82.6) 1.18 (1.08–1.27)a
 Asian 54.8 (47.7–61.9) 1.00 (0.92–1.09)
 Other 60.7 (55.9–65.4) 1.06 (1.00–1.13)
Mother’s educational level
 <High schoolb 62.7 (57.3–68.1) ref.
 High school 57.5 (54.2–60.8) 0.91 (0.85–0.97)a
 Some college or college graduate 56.1 (53.4–58.8) 0.90 (0.84–0.96)a
 >College graduate 61.2 (59.1–63.3) 0.94 (0.88–1.01)
Mother’s married status
 Married or living with partnerb 59.1 (57.4–60.8) ref.
 Widowed, divorced, or separated 61.0 (58.1–63.9) 1.04 (1.01–1.08)a
 Never married 57.5 (52.5–62.5) 1.03 (0.96–1.10)
Mother’s age
 ≤34 yb 58.9 (54.0–63.9) ref.
 35–44 y 58.5 (56.5–60.5) 1.02 (0.96–1.09)
 ≥45 y 60.2 (58.1–62.3) 1.02 (0.95–1.08)
Place of birth
 Born in United Statesb 59.2 (57.8–60.6) ref.
 Born outside United States 63.1 (55.4–70.8) 1.06 (0.97–1.15)
Income to poverty ratio
 <133%b 62.3 (58.9–65.7) ref.
 133% to <322% 55.0 (52.3–57.7) 0.94 (0.89–0.98)a
 322% to <503% 58.9 (56.1–61.7) 0.93 (0.88–0.99)a
 ≥503% 61.5 (58.7–64.4) 1.02 (0.96–1.07)
Medical insurancec
 Private onlya 58.2 (56.1–60.4) ref.
 Any Medicaid 62.6 (59.7–65.4) 1.07 (1.02–1.12)a
 Otherd 56.2 (51.3–61.2) 1.03 (0.97–1.08)
 Uninsured 52.4 (43.9–60.9) 0.94 (0.83–1.05)
Provider contacts within past year
 Noneb 52.5 (48.8–56.2) ref.
 1 58.6 (56.3–61.0) 1.05 (0.99–1.11)
 2–3 61.8 (59.7–63.9) 1.08 (1.02–1.14)a
 ≥4 61.9 (58.9–64.9) 1.06 (1.00–1.13)a
Well child visit at age 11–12 ye
 Yes 64.4 (62.6–66.3) 1.17 (1.11–1.23)a
 Nob 46.5 (43.2–49.8) ref.
 Don’t know 58.0 (55.5–60.4) 1.07 (1.00–1.13)a
Number of providers
 1 61.1 (59.3–62.9) 1.12 (1.05–1.19)a
 2 59.3 (56.7–61.8) 1.10 (1.03–1.17)a
 ≥3b 50.9 (46.9–54.9) ref.
MSA
 MSA Principal Cityb 60.0 (57.9–62.2) ref.
 MSA Non–Principal City 59.8 (57.9–61.8) 0.98 (0.95–1.02)
 Non–MSA 54.4 (51.1–57.7) 0.94 (0.89–0.98)a
Region
 Northeast 64.4 (61.8–67.0) 1.02 (0.96–1.07)
 Midwest 61.6 (59.4–63.9) 1.01 (0.96–1.07)
 South 56.0 (53.9–58.1) 0.96 (0.91–1.01)
 Westb 59.4 (55.1–63.7) ref.
Facility type
 All private facilitiesb 58.6 (56.7–60.5) ref.
 All public facilities 56.3 (52.1–60.6) 1.01 (0.96–1.07)
 All hospital facilities 59.6 (56.1–63.1) 1.00 (0.96–1.05)
 All sexually transmitted diseases, school, and teen clinics or other facilities 54.7 (44.1–65.4) 0.94 (0.80–1.07)
 Mixedf 64.7 (61.4–67.9) 1.07 (1.03–1.12)a
 Otherg 45.8 (33.8–57.8) 0.70 (0.55–0.85)a
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CI, confidence interval; ref., reference.

a

P <05 compared with reference level.

b

Reference level.

c

Insurance categories are mutually exclusive.

d

Children’s Health Insurance Program, Indian Health Service, military, and some private.

e

Status of health-care visit at age 11 to 12 y based on provider reported data.

f

Mixed indicates that the facility is identified to be in more than one of the facility categories such as private, public, hospital, STD, school, and teen clinics.

g

Includes military, WIC clinics, and pharmacies.

DISCUSSION

Overall, HPV vaccination coverage among adolescents increased from 2015 to 2020. Vaccination coverage (≥1 dose) significantly increased across almost all levels of variables assessed. There were larger increases among males than females and difference between males and females narrowed during this time. Vaccination coverage significantly differed over the years assessed by age group, race and ethnicity, provider recommendation, well-child visit, number of provider visits within previous 12 months, and other characteristics. Even though coverage substantially increased over the years, ~25% of adolescents had not received at least 1 dose of HPV vaccination in 2020. Targeted strategies are needed to increase coverage and narrow down inequalities.

Overall, HPV vaccination coverage (≥1 dose) among adolescents 13 to 17 years in 2020 was 76.8% among females, and 73.7% among males. Historically, coverage in female adolescents increased from 25.1% in 2007 to 62.8% in 2015 (about 8 years since vaccination was initially recommended).12–14 Likewise, among males, HPV vaccination coverage has also substantially increased since the vaccine was first recommended for males in 2011.15 Coverage among males increased from 20.9% in 2012 to 73.7% in 2020 (about 9 years since vaccination was first recommended for male adolescents).16 Data from our study found that coverage in adolescents during 2015 through 2020 significantly increased a total of 24.0 percentage points for males and 14.0 percentage points for females, with an average increase of 4.7 percentage points annually for males and 2.7 percentage points annually for females. During this time, the difference between coverage among males and females decreased from 13 to 3 percentage points. Coverage among adolescents substantially increased in recent years is encouraging, especially among males.

Studies consistently have found that a provider recommendation is highly associated with HPV vaccination.17–19 Results from our study confirmed this association. One study showed that the prevalence of providers strongly recommending HPV vaccination substantially increased over the years for female and male children.20 However, based on data from the 2020 NIS-Teen, even among those who reported a provider recommendation for the vaccine, only 80.7% received vaccination, indicating that other factors might also contribute to adolescents not being vaccinated. The result from our study also showed that the prevalence of receiving a provider recommendation among adolescents substantially increased during 2015 to 2020. One study found coverage in female adolescents (≥1 dose) was 58.3% in 2008 to 2009 among adolescents with a provider recommendation compared with those without (20.7%).21 Another study among male adolescents showed that “a provider recommendation was associated with higher HPV vaccination coverage across the majority of states.”18 Studies also showed that “recommendations from providers increase parental acceptance of HPV vaccination and that parents change their minds about delaying and refusing vaccines because of information or assurances from health care providers.”22,23 However, our study showed that 18.5% of parents of adolescents did not receive a provider recommendation. Providers should routinely recommend the vaccine and highlight importance of vaccination in preventing HPV-related cancers.

The results from our study demonstrated that provider contacts and a well–child visit had a positive impact on vaccination coverage. Persons with more provider contacts may have more chance to consult with providers regarding their immunization situation, get a recommendation, and receive vaccination. The ACIP and partner organizations recommend a well–child visit to vaccinate teens who have not initiated vaccinations; administer a booster dose if needed; and provide other recommended preventive services.24,25 Even though the well–child visit provides a chance to discuss vaccination status and receive recommended vaccinations, only 46.3% to 50.4% of children had a well–child visit at age 11 to 12 years based on the 2015 to 2020 NIS–Teen. Providers should educate parents and adolescents about the diseases that can be prevented by vaccines, review medical records, and administer all age-appropriate vaccinations at all health care visits.26

Findings from our study indicated that coverage for adolescents residing in non-MSA areas was consistently and significantly lower than those residing in MSA principal cities in all years assessed, and this association remained after controlling for other variables. The inequity in coverage by MSA is not clear; however, the lower provider recommendation rate and less vaccination-related information available in non-MSA areas might contribute to coverage disparity.8,27,28

HPV vaccination coverage among adolescents was higher for non-Hispanic Black, Hispanic, and AIAN adolescents compared with non-Hispanic White adolescents. Increased vaccine access by the Vaccine for Children program (providing free recommended vaccines to children without health insurance and children who are under-insured) or risk-based provider recommendations for HPV on the perceived level of the patient’s risk for HPV-related cancer morbidity and mortality might contribute to the increased HPV vaccination coverage in these minority groups.29–31

Findings from our study indicated that mothers with higher education were associated with decreased HPV vaccination coverage, which is similar to the findings from the previous reports.18,27 Another study also found that intent to have their child vaccinated was lower among mothers with higher education.31 Further research should be conducted to understand why teens whose mothers with a higher education had lower HPV vaccination coverage.

The findings in this study are subject to 2 limitations. First, the overall household response rate in 2020 was 20.7%, and 45.2% of adolescents with completed interviews had adequate provider data. However, the estimated total survey error of HPV vaccination coverage from the 2018 NIS–Teen is −1.6 percentage points, indicating HPV vaccination coverage based on NIS–Teen was only ~1.6 percentage points too low.9 Additionally, the distribution of characteristics (eg, age, gender, and race and ethnicity) from the 2020 NIS–Teen were close to those observed in the child core data of the 2020 National Health Interview Survey (CDC unpublished data). Second, bias in estimates might remain even after adjustment for household and provider nonresponse and phoneless households.

In conclusion, HPV vaccination coverage among adolescents aged 13 to 17 years increased during 2015 to 2020. Vaccination coverage significantly differed over the years when assessed by provider recommendation, well-child visit at age 11 to 12 years, number of provider contacts in the past 12 months, age group, race and ethnicity, and other characteristics. Targeted strategies should be implemented to providers who serve different communities, particularly those who serve non-Hispanic White children. The association between mother’s education and HPV vaccination coverage indicated that interventions should consider maternal education attainment, and further research should be conducted to understand why teens whose mothers with a higher education had lower HPV vaccination coverage. It is encouraging that coverage among male adolescents substantially increased in recent years. To increase HPV vaccination coverage and further reduce HPV-related morbidity and mortality, providers, parents, and adolescents should use every health care visit as a chance to review vaccination histories and ensure that every adolescent receives the HPV vaccine and other needed vaccines.32–36

WHAT’S KNOWN ON THIS SUBJECT

Human Papillomavirus (HPV) is the most common sexually transmitted infection. Vaccination is an important tool to prevent and control HPV infection and its complications. HPV vaccination in the United States has been recommended for girls since 2006 and for boys since 2011.

WHAT THIS STUDY ADDS

This study examines HPV vaccination trends. HPV vaccination coverage among adolescents increased during 2015 to 2020. Coverage increased faster among males than females and differences by sex narrowed. Receiving provider recommendation is important to increase vaccination coverage.

ACKNOWLEDGMENTS

We thank James A. Singleton of the Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, for his important review and contributions.

FUNDING:

No external funding.

ABBREVIATIONS

HPV

human papillomavirus

ACIP

Advisory Committee on Immunization Practices

PR

prevalence ratio

95% CI

95% confidence interval

RDD

random-digit–dial

CDC

Centers for Disease Control and Prevention

STD

sexual transmitted diseases

WIC

Women, Infants, and Children

MSA

metropolitan statistical area

NIS-Teen

National Immunization Survey-Teen

VFC

Vaccines for Children

CASRO

The Council of American Survey Research Organizations

NORC

National Opinion Research Center

Footnotes

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

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