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. Author manuscript; available in PMC: 2018 Sep 1.
Published in final edited form as: Am J Prev Med. 2017 May 8;53(3):373–384. doi: 10.1016/j.amepre.2017.03.022

Impact of Provider Recommendation on Tdap Vaccination of Adolescents Aged 13–17 Years

Peng-jun Lu 1, David Yankey 1, Jenny Jeyarajah 1, Alissa O’Halloran 1, Sarah A Meyer 2, Laurie D Elam-Evans 1, Sarah Reagan-Steiner 1
PMCID: PMC5794009  NIHMSID: NIHMS926300  PMID: 28495221

Abstract

Introduction

Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination has been recommended for adolescents in the U.S. since 2006. Information on Tdap vaccination by provider recommendation is limited. The purpose of this study is to assess recent Tdap vaccination by provider recommendation status among adolescents aged 13–17 years.

Methods

The 2013 National Immunization Survey-Teen data (N=18,948) were analyzed in 2016 to assess national and state-specific Tdap vaccination coverage disparities among adolescents by provider recommendation status, and other demographic and access to care variables. Multivariable logistic regression analysis and predictive marginal modeling evaluated associations between Tdap vaccination and provider recommendation status and other factors among adolescents aged 13–17 years.

Results

Overall, only 56.9% of adolescents aged 13–17 years received a provider recommendation for Tdap. Coverage was significantly higher among adolescents with a provider recommendation (88.6%) compared with those without a provider recommendation (80.5%) (p < 0.05). Multivariable logistic regression showed that characteristics independently associated with a higher likelihood of Tdap vaccination included receiving a provider recommendation, Hispanic ethnicity, having two to three physician contacts in the past 12 months, having one or two vaccination providers, and receiving vaccinations from more than one type of facility (p < 0.05).

Conclusions

Provider recommendations were significantly associated with Tdap vaccination among adolescents aged 13–17 years. However, 43% of parents of adolescents did not receive a provider recommendation. Evidence-based strategies such as standing orders and provider reminders alone or health systems interventions in combination should be taken to improve provider recommendation and Tdap vaccination coverage.

INTRODUCTION

Pertussis, a respiratory illness caused by the bacteria Bordetella pertussis, remains endemic in the U.S. despite longstanding routine childhood pertussis vaccination. Since the 1980s, the number of reported pertussis cases has steadily increased, especially among adolescents and adults, likely due, in part, to waning immunity from the childhood vaccination series.1–4 Overall, there were 32,971 reported cases of pertussis during 2014 compared with 25,824 cases reported during 2004.2 The number of pertussis cases is likely under-reported because individuals with pertussis, particularly adolescents and adults, can have nonspecific symptoms, with pertussis often going undiagnosed.1,3,4 To protect adolescents from pertussis infection, the Advisory Committee on Immunization Practices recommended the tetanus, diphtheria, and acellular pertussis vaccine (Tdap) in 2005 as a routine booster vaccination for all adolescents aged 11–18 years, with a preferred age of administration at 11–12 years.3,4 Overall, by 2013, Tdap vaccination coverage was 84.7% among adolescents aged 13–17 years.5

Provider recommendations are strongly associated with vaccination.6–9 Overall Tdap vaccination has been assessed previously, but comprehensive assessment of the impact of provider recommendation on Tdap vaccination coverage and prevalence of provider recommendation among adolescents at the national and state levels have not been reported previously.5 The purpose of this study is to use data from the 2013 National Immunization Survey-Teen (NIS-Teen) to assess (1) Tdap vaccination and prevalence of provider recommendation of the vaccine; (2) provider recommendation and other factors associated with Tdap vaccination; and (3) coverage disparities among adolescents with and without a provider recommendation at the national and state levels. Such information is useful to develop tailored strategies to improve provider recommendation and Tdap vaccination coverage among adolescents.

METHODS

The 2013 NIS-Teen data were analyzed in 2016. NIS-Teen is a national, random-digit-dial telephone survey conducted by the Centers for Disease Control and Prevention (CDC). The objective of the NIS-Teen is to provide timely, detailed information regarding vaccination coverage among adolescents aged 13–17 years. Data are collected in the NIS-Teen in two phases. In the first phase, a random-digit-dial telephone interview is conducted to identify households with age-eligible adolescents (aged 13–17 years at the time of interview) and to collect demographic information from the parent or guardian on adolescent, maternal, and household characteristics. Also, the interview includes questions on the adolescent’s reported vaccination history. After completing the interview, consent is requested to contact the 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.5,10

In 2013, the NIS-Teen sampling plan included independent samples of households with a landline and also households with a cell phone.5,10 In total, there were 18,948 adolescents with adequate provider data from landline (representing 62.0% of all adolescents from the landline sample with completed household interviews) and cell samples (representing 56.4% of all adolescents from the cell phone sample with completed household interviews) combined excluding the U.S. Virgin Islands and Guam. The Council of American Survey Research Organizations response rates were 51.1% for landline and 23.3% for cell phone.5,10,11

Provider recommendation status was assessed by asking parents/guardians whether they have received a provider recommendation of the vaccine. Tdap vaccination was assessed by provider recommendation and controlled covariates that may be associated with vaccination coverage empirically or based on previous studies,6–8 which included age group; gender; race/ethnicity; mother’s educational level; mother’s marital status; mother’s age; birth country; poverty level; type of health insurance and vaccine finance; number of physician contacts within the past 12 months; provider-reported healthcare visit at age 11–12 years; number of vaccination providers reported by parents; vaccination facility type (public, private, hospital, sexually transmitted disease/school/teen clinics, mixed [including facilities in more than one category such as private, public, hospital, sexually transmitted disease/school/teen clinics], and others [such as military, Special Supplemental Nutrition Program for Women, Infants, and Children clinics, and pharmacies]); metropolitan statistical area; and U.S. Census region. Prevalence of provider recommendation and vaccination coverage at the state level were assessed. Vaccination by middle school entry requirement, which was in effect as of 2013 based on information from immunization.org, was also evaluated.12

The authors used SUDAAN, version 11.0.1, to calculate point estimates and 95% CIs adjusted for the complex sample design of NIS-Teen. All analyses account for the complex sampling plan of NIS-Teen and the survey sampling weights.5,6 Chi-square tests were used to examine differences in population distribution between those with and without a provider recommendation. The study used t-tests to examine prevalence of provider recommendation and vaccination coverage compared with the reference group within each variable, as well as national and state-specific vaccination coverage differences between those with and without a provider recommendation. All tests were conducted with the significance level set at α < 0.05. Multivariable logistic regression and predictive marginal modeling were conducted to derive the adjusted prevalence ratio (PR). NIS-Teen was approved by CDC, National Center for Health Statistics Research Ethics Review Board, and the NORC at the University of Chicago IRB.

RESULTS

Table 1 shows the demographic characteristics of the study population. Overall, a majority of adolescents were non-Hispanic white (55.0%); had mothers with more than a high school education (62.1%); had mothers who are currently married (66.1%); were born in the U.S. (95.5%); were living in a household with an income >133% of the federal poverty level (66.9%); had one vaccination provider (50.6%); had at least one physician contact within the past year (83.6%); and received all reported vaccination from providers in a private facility (50.4%).

Table 1.

Sample Characteristics of Adolescents Aged 13–17 Years in the U.S.—NIS-Teen 2013

Characteristic Sample Weighted
%		 Prevalence of provider recommendation for vaccine,
weighted %
Total 18,948 100.0 56.9
Age (years)
  13–15a 11,651 60.7 56.7
  16–17 7,297 39.3 57.1
Gender
  Malea 9,906 51.2 57.1
  Female 9,042 48.8 56.6
Race/ethnicity
  Non-Hispanic whitea 12,499 55.0 63.9
  Non-Hispanic black 1,701 13.8 47.7b
  Hispanic 2,872 22.1 42.4b
  American Indian/Alaskan Native 289 1.0 57.7
  Asian 586 3.4 67.0
  Other 1,001 4.7 62.0
Mother’s educational level
  <High schoola 2,069 13.8 34.4
  High school 3,298 24.2 48.8b
  Some college or college graduate 5,266 26.0 57.0b
  >College graduate 8,315 36.1 70.4b
Mother’s married status
  Marrieda 13,671 66.1 59.4
  Widowed/divorced/separated 3,589 22.8 55.8b
  Never married 1,532 11.0 44.0b
Mother’s age (years)
  ≤34a 1,651 10.2 47.9
  35–44 7,964 44.6 53.5b
  ≥45 9,333 45.3 62.2b
Adolescent’s birth country
  Born in U.S.a 18,237 95.5 57.8
  Born outside U.S. 654 4.5 36.6b
Income to poverty ratio
  <133%a 4,650 33.1 41.7
  133%–<322% 5,579 29.8 57.2b
  322%–<503% 4,282 18.5 67.7b
  ≥503% 4,437 18.6 72.4b
Medical insurance and vaccine financec
  Private insurance onlya 8,815 43.2 67.7
  VFC eligible–Medicaid/IHS/AIAN (All) 7,351 44.5 50.6b
  VFC eligible–uninsured 888 5.7 37.6b
  CHIP (public) 511 2.9 55.1b
  Military 566 2.7 58.6b
  Other 133 0.9 40.9b
Physician contacts within past year
  Nonea 2,699 16.4 47.5
  1 5,331 27.8 56.5b
  2–3 6,706 35.6 60.4b
  ≥4 4,128 20.1 58.8b
Well child visit at age 11–12 yearsd
  Yesa 7,963 40.2 63.9
  No 5,063 24.7 48.4b
  Don’t know 5,922 35.0 54.9b
Number of vaccination providers
  1 9,267 50.6 58.2
  2 5,630 29.0 54.7
  ≥3a 4,024 20.3 56.7
Metropolitan statistical area (MSA)
  Urban area 7,240 38.9 52.7
  Suburban area 7,430 47.8 61.6b
  Rural areaa 4,278 13.3 52.3
Region
  Northeast 3,893 16.9 64.8b
  Midwest 4,297 21.7 59.0
  South 6,246 37.5 52.8
  Westa 4,512 24.0 55.9
Vaccination facility type
  All private facilitiesa 8,719 50.4 63.0
  All public facilities 2,795 15.4 37.6b
  All hospital facilities 1,942 9.0 60.5
  All STD/school/teen clinics or other facilities 320 1.8 39.9b
  Mixede 4,774 21.9 56.5b
  Otherf 287 1.5 57.8
Parental report of provider recommendation for vaccine
  Yesa 10,258 56.9
  No 6,690 43.1
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Note: Boldface indicates statistical significance (p < 0.05).

a

Reference level.

b

p< 0.05 by t-test compared with reference group.

c

Insurance categories are mutually exclusive.

d

Status of healthcare visit at age 11–12 years based on provider-reported data.

e

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

f

Includes military, WIC clinics, and pharmacies.

AIAN, American Indian/Alaska Native; CHIP, Children’s Health Insurance Program; IHS, Indian Health Service; NIS, National Immunization Survey; STD, sexually transmitted diseases; VFC, Vaccines for Children Program; WIC, the National Special Supplemental Nutrition Program for Women, Infants, and Children.

Overall, only 56.9% of adolescents aged 13–17 years received a provider recommendation for Tdap (Table 1). Number of physician contacts in the past year and well-child visit at age 11–12 years were significantly associated with prevalence of provider recommendation for Tdap vaccine; this is particularly important because physician contacts and well-child visits might provide chances for providers to recommend vaccines to their patients. Prevalence of provider recommendation was significantly higher among those with one (56.5%); two to three (60.4%); and four or more (58.8%) physician contacts compared with those without a physician contact within the past year (47.5%). Prevalence of provider recommendation was significantly higher among those who had a well-child visit at age 11–12 years (63.9%) compared with those who did not (48.4%). Other variables that were significantly associated with prevalence of provider recommendation included race/ethnicity, mother’s educational level, mother’s marital status, mother’s age, adolescent’s birth county, poverty level, medical insurance, number of vaccination providers, metropolitan statistical area, region, and vaccination facility type. Additionally, prevalence of provider recommendation was the lowest among adolescents with mothers having less than high school education (34.4%), then born outside the U.S. (36.6%), and highest among those with mother’s education beyond college graduation (70.4%) (Table 1).

Overall, Tdap vaccination coverage was 84.7% among adolescents aged 13–17 years. Coverage was significantly higher among adolescents with a provider recommendation (88.6%) compared with those without a provider recommendation (80.5%) (p < 0.05) (Table 2). Coverage was significantly higher among adolescents aged 13–15 years (86.3%) compared with those aged 16–17 years (82.3%) (p < 0.05) (Table 2). In multivariable analyses, characteristics independently associated with a higher likelihood of Tdap vaccination included receiving a provider recommendation (PR=1.06); being of Hispanic ethnicity (PR=1.05); having two three physician contacts in the past 12 months (PR=1.05); having one or two vaccination providers (PR=1.07, and PR=1.06, respectively); and receiving vaccinations from more than one type of facility (PR=1.09) (p < 0.05) (Table 3). Adolescents aged 16–17 years (PR=0.97); those not having a well-child visit at age 11–12 years (PR=0.88); and those living in the South (PR=0.95) had a lower likelihood of Tdap vaccination (p < 0.05) (Table 3). Coverage among adolescents with a provider recommendation was significantly higher across the majority of demographic and access to care characteristics compared with those without a provider recommendation (Table 2).

Table 2.

Tdap Vaccination Coverage (≥1 Dose) Among Adolescents Aged 13–17 Years—NIS-Teen 2013

Tdap vaccination coverage
Parental report of provider recommendation
for vaccine
Characteristic Overall, % (95% CI) Yes, % (95% CI) No, % (95% CI)
Total 84.7 (83.7, 85.7) 88.6 (87.5, 89.7) 80.5 (78.6, 82.3)a
Age (years)
  13–15b 86.3 (85.1, 87.4) 89.8 (88.3, 91.0) 82.2 (80.0, 84.2)a
  16–17 82.3 (80.5, 84.0)c 86.9 (85.0, 88.7)c 77.8 (74.3, 81.0)a,c
Gender
  Maleb 84.4 (83.0, 85.8) 88.4 (86.7, 89.8) 80.1 (77.3, 82.7)a
  Female 85.0 (83.6, 86.3) 88.9 (87.3, 90.4) 80.9 (78.2, 83.3)a
Race/ethnicity
  Non-Hispanic whiteb 84.8 (83.6, 85.9) 88.3 (86.9, 89.6) 79.4 (77.0, 81.6)a
  Non-Hispanic black 82.7 (79.4, 85.5) 86.0 (81.5, 89.6) 80.6 (75.1, 85.1)
  Hispanic 84.9 (82.2, 87.3) 89.8 (86.6, 92.3) 81.7 (77.2, 85.4)a
  American Indian/Alaskan Native 84.8 (76.2, 90.7) 89.5 (79.0, 95.0) 84.5 (74.6, 91.0)
  Asian 88.8 (84.7, 91.9) 93.2 (88.2, 96.1) 84.6 (75.1, 90.9)
  Other 86.1 (81.9, 89.4) 91.1 (86.4, 94.3) 80.0 (71.2, 86.7)a
Mother’s educational level
  <High schoolb 83.6 (80.5, 86.4) 87.2 (82.8, 90.6) 82.8 (78.1, 86.6)
  High school 81.8 (79.2, 84.1) 87.4 (84.1, 90.2) 76.8 (72.4, 80.8)a
  Some college or college graduate 83.9 (82.1, 85.6) 87.1 (84.7, 89.2) 80.9 (77.7, 83.7)a
  >College graduate 87.7 (86.4, 88.9)c 90.3 (88.8, 91.6) 82.2 (78.9, 85.1)a
Mother’s married status
  Marriedb 85.7 (84.5, 86.8) 89.5 (88.2, 90.6) 80.8 (78.4, 83.1)a
  Widowed/divorced/separated 83.9 (81.8, 85.8) 86.7 (83.7, 89.2) 82.9 (79.6, 85.8)
  Never married 81.9 (78.0, 85.3)c 87.3 (82.3, 91.1) 77.2 (70.8, 82.6)a
Mother’s age (years)
  ≤34b 81.9 (78.5, 84.9) 83.3 (77.6, 87.7) 80.7 (75.9, 84.7)
  35–44 83.7 (82.0, 85.2) 88.4 (86.7, 89.9)c 79.3 (76.0, 82.2)a
  ≥45 86.4 (85.1, 87.6)c 89.8 (88.1, 91.2)c 81.9 (79.3, 84.2)a
Adolescent’s birth country
  Born in U.S.b 84.9 (83.9, 85.9) 88.7 (87.5, 89.7) 80.7 (78.7, 82.4)a
  Born outside U.S. 80.4 (73.0, 86.1) 87.8 (80.5, 92.6) 78.2 (66.6, 86.7)
Income to poverty ratio
  <133%b 83.2 (81.1, 85.1) 87.4 (84.7, 89.7) 80.7 (77.3, 83.6)a
  133%–<322% 82.6 (80.8, 84.3) 86.6 (84.3, 88.6) 78.6 (75.4, 81.5)a
  322%–<503% 87.1 (85.0, 88.8)c 90.5 (88.3, 92.3) 82.1 (77.4, 86.0)a
  ≥503% 88.5 (86.6, 90.1)c 90.7 (88.6, 92.6)c 82.4 (77.7, 86.3)a
Medical insurance and vaccine financed
  Private onlyb 88.2 (87.0, 89.3) 91.4 (90.0, 92.6) 83.1 (80.2, 85.6)a
  VFC eligible–Medicaid/IHS/AIAN (All) 85.4 (83.8, 86.8)c 88.0 (86.0, 89.8)c 82.8 (80.1, 85.2)a
  VFC eligible–uninsured 76.8 (71.6, 81.4)c 82.7 (72.6, 89.6)c 77.0 (70.0, 82.7)
  CHIP (public) 84.3 (78.7, 88.7) 88.2 (79.0, 93.7) 81.4 (73.0, 87.6)
  Military 86.2 (79.3, 91.1) 90.5 (80.4, 95.7) 80.2 (67.8, 88.7)
  Other 74.5 (49.7, 89.6) 89.8 (79.0, 95.3) 68.4 (30.6, 91.4)
Physician contacts within past year
  Noneb 79.1 (75.8, 82.1) 86.0 (82.4, 89.1) 75.0 (69.2, 80.1)a
  1 84.0 (82.1, 85.8)c 88.4 (86.0, 90.4) 79.5 (75.8, 82.7)a
  2–3 86.9 (85.4, 88.2)c 89.9 (88.0, 91.5)c 83.4 (80.8, 85.7)a,c
  ≥4 86.3 (84.2, 88.1)c 88.4 (86.0, 90.5) 82.3 (78.0, 85.9)a,c
Well-child visit at age 11–12 yearse
  Yesb 93.0 (91.8, 94.0) 93.2 (91.5, 94.5) 92.0 (89.6, 93.9)
  No 77.4 (75.2, 79.4)c 83.4 (80.6, 85.9)c 73.8 (70.2, 77.1)a,c
  Don’t know 80.5 (78.5, 82.2)c 85.8 (83.7, 87.8)c 75.2 (71.5, 78.6)a,c
Number of providers
  1 86.0 (84.7, 87.3)c 89.5 (87.9, 90.9)c 82.1 (79.4, 84.5)a,c
  2 85.4 (83.6, 86.9)c 89.1 (86.9, 90.9)c 81.2 (78.0, 84.0)a,c
  ≥3b 80.9 (78.2, 83.3) 85.8 (82.9, 88.3) 75.6 (70.5, 80.1)a
Metropolitan statistical area (MSA)
  Urban area 84.8 (83.1, 86.3)c 87.6 (85.6, 89.4) 81.6 (78.6, 84.3)a,c
  Suburban area 85.8 (84.3, 87.2)c 89.8 (88.2, 91.3)c 81.2 (77.9, 84.0)a,c
  Rural areab 80.6 (78.3, 82.7) 86.6 (83.7, 89.1) 75.3 (71.7, 78.7)a
Region
  Northeast 89.3 (87.6, 90.8)c 92.3 (90.3, 93.9) 84.5 (80.7, 87.7)a
  Midwest 84.1 (82.3, 85.6) 87.8 (85.7, 89.7) 80.2 (77.1, 83.1)a
  South 82.2 (80.5, 83.7)c 85.8 (83.5, 87.8)c 79.0 (76.4, 81.5)a
  Westb 86.1 (83.3, 88.4) 90.7 (88.0, 92.8) 80.8 (74.9, 85.6)a
Facility type
  All private facilitiesb 86.7 (85.4, 87.9) 89.6 (88.0, 90.9) 82.5 (79.8, 85.0)a
  All public facilities 78.5 (75.2, 81.4)c 81.7 (77.1, 85.6)c 76.3 (71.4, 80.6)c
  All hospital facilities 79.2 (75.0, 82.9)c 84.6 (80.1, 88.2)c 68.1 (59.2, 75.8)a,c
  All STD/school/teen clinics or other facilities 78.6 (70.2, 85.2)c 78.2 (61.0, 89.2)c 78.7 (67.5, 86.7)
  Mixedf 88.9 (87.3, 90.3)c 91.9 (89.8, 93.7) 86.0 (83.3, 88.4)a
  Otherg 80.0 (68.0, 88.3) 87.5 (77.1, 93.6) 71.7 (48.0, 87.4)
Parental report of provider recommendation for vaccine
  Yesb 88.6 (87.5, 89.7)
  No 80.5 (78.6, 82.3)c
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Note: Boldface indicates statistical significance (p < 0.05).

a

p <0.05 by t-test comparing provider recommendation versus no provider recommendation.

b

Reference level.

c

p <0.05 by t-test comparing against reference level.

d

Insurance categories are mutually exclusive.

e

Status of healthcare visit at age 11–12 years 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/teen clinics.

g

Includes military, WIC clinics, and pharmacies.

AIAN, American Indian/Alaska Native; CHIP, Children’s Health Insurance Program; IHS, Indian Health Service; NIS, National Immunization Survey; STD, sexually transmitted diseases; Tdap, tetanus, diphtheria, and acellular pertussis; VFC, Vaccines for Children Program.

Table 3.

Multivariable Logistic Regression and Predictive Marginal Analysis of Tdap Vaccination (≥1 Dose) Among Adolescents

Characteristic Adjusted prevalence ratioa (95% CI)
Age (years)
  13–15b ref
  16–17 0.97 (0.95, 0.99)c
Race/ethnicity
  Non-Hispanic whiteb ref
  Non-Hispanic black 1.03 (0.99, 1.07)
  Hispanic 1.05 (1.01, 1.08)c
  American Indian/Alaskan Native 1.05 (0.99, 1.12)
  Asian 1.05 (1.00, 1.10)
  Other 1.03 (0.98, 1.08)
Physician contacts within past year
  Noneb ref
  1 1.03 (0.99, 1.07)
  2–3 1.05 (1.01, 1.09)c
  ≥4 1.04 (1.00, 1.08)
Well-child visit at age 11–12 yearsd
  Yesb ref
  No 0.88 (0.86, 0.91)c
  Don’t know 0.90 (0.88, 0.92)c
Number of providers
  1 1.07 (1.03, 1.11)c
  2 1.06 (1.02, 1.10)c
  ≥3b ref
Region
  Northeast 0.99 (0.96, 1.03)
  Midwest 0.97 (0.94, 1.00)
  South 0.95 (0.92, 0.98)c
  Westb ref
Facility type
  All private facilitiesb ref
  All public facilities 0.99 (0.95, 1.03)
  All hospital facilities 0.96 (0.91, 1.00)
  All STD/school/teen clinics or other facilities 0.99 (0.91, 1.07)
  Mixede 1.09 (1.06, 1.12)c
  Otherf 1.06 (0.97, 1.16)
Parental report of provider recommendation for vaccine
  Yes 1.06 (1.04, 1.08)c
  Nob ref
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Note: Boldface indicates statistical significance (p < 0.05).

a

Prevalence ratios were also adjusted by several variables that were not significant in the model, and those variables include gender, mother’s educational level, mother’s marital status, mother’s age, birth country, poverty level, type of health insurance and vaccine finance, and metropolitan statistical area (MSA).

b

Reference level.

c

p <0.05 compared to reference level.

d

Status of healthcare visit at age 11–12 years based on provider-reported data.

e

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

f

Includes military, WIC clinics, and pharmacies.

STD, sexually transmitted diseases; Tdap, Tetanus, diphtheria, and acellular pertussis; WIC, the National Special Supplemental Nutrition Program for Women, Infants, and Children.

By state, prevalence of provider recommendation for Tdap among all adolescents aged 13–17 years ranged from 36.6% in Mississippi to 77.9% in Maine with a median of 57.6% (Table 4). Tdap vaccination coverage among all adolescents aged 13–17 years ranged from 59.3% in Mississippi to 95.5% in Rhode Island with a median of 84.2%. Tdap coverage among those with a provider recommendation ranged from 72.1% in Mississippi to 97.5% in North Dakota with a median of 88.6% compared with those without a provider recommendation (ranging from 52.9% in Mississippi to 96.4% in Rhode Island with a median of 81.2%) (Table 4). Point estimates of Tdap vaccination coverage were statistically significantly higher among adolescents with a provider recommendation compared with adolescents without a provider recommendation in 17 states (Table 4). Coverage differences ranged from –2.1% in Virginia to 26.2% in Maryland with a median of 7.2%. State prevalence of receiving provider recommendation also correlated positively with overall state Tdap vaccination coverage (r =0.50, p < 0.01). Among 11 states without a middle school vaccination requirement as of 2013, eight states had lower Tdap vaccination coverage than national coverage though only coverage in South Dakota was significantly lower than the national coverage (Table 4).

Table 4.

Tdap Vaccination Coverage Among Adolescents, by State and Provider Recommendation for Tdap Vaccination

Sample
size, N		 Prevalence of
provider
recommendation
for Tdap, %
(95% CI)		 Tdap vaccination coverage Coverage
difference,a %
(95% CI)
Overall, %
(95% CI)		 With provider
recommendation,
% (95% CI)		 Without
provider
recommendation,
% (95% CI)
National 18,948 56.9 (55.5, 58.3) 84.7 (83.7, 85.7) 88.6 (87.5, 89.7) 80.5 (78.6, 82.3) 8.2 (6.0,10.3)b
Alabama 324 59.5 (52.9, 66.0) 86.4 (81.2, 90.4) 88.6 (81.2, 93.4) 86.2 (77.4, 91.9) 2.5 (−6.8, 11.8)
Alaska 338 53.7 (46.9, 60.4) 70.8 (64.4, 76.5) 79.6 (71.6, 85.8) 61.7 (51.1, 71.4) 17.9 (5.4, 30.3)b
Arizona 391 46.5 (39.8, 53.1) 83.7 (78.2, 88.0) 87.2 (78.9, 92.6) 82.2 (73.0, 88.8) 5.0 (−5.3, 15.3)
Arkansasc 323 38.6 (32.1, 45.2) 75.6 (69.7, 80.7) 80.9 (71.3, 87.9) 72.8 (64.6, 79.8) 8.1 (−3.1, 19.4)
California 338 54.4 (47.4, 61.4) 87.9 (82.5, 91.8) 92.9 (87.4, 96.1) 81.2 (69.8, 88.9) 11.8 (1.4, 22.1)b
Colorado 345 64.9 (58.8, 71.1) 86.5 (81.4, 90.4) 89.2 (82.2, 93.7) 80.2 (70.0, 87.6) 9.0 (−1.4, 19.4)
Connecticut 332 66.9 (60.0, 73.8) 90.4 (85.2, 93.8) 93.8 (89.0, 96.6) 80.4 (65.5, 89.9) 13.4 (0.7, 26.1)b
Delawarec 353 61.9 (55.3, 68.6) 83.9 (78.8, 88.0) 86.5 (80.3, 91.0) 76.3 (65.0, 84.8) 10.2 (−1.0, 21.4)
District of Columbia 195 49.4 (38.1, 60.7) 80.8 (70.5, 88.1) 82.7 (65.5, 92.3) 74.8 (57.1, 86.9) 7.9 (−12.2, 27.9)
Florida 330 52.3 (44.8, 59.8) 84.2 (77.9, 88.9) 85.6 (75.0, 92.2) 82.2 (72.0, 89.2) 3.4 (−8.6, 15.4)
Georgiac 258 55.8 (47.4, 64.2) 81.1 (73.5, 87.0) 81.7 (69.9, 89.6) 83.2 (70.6, 91.1) −1.5 (−15.6, 12.6)
Hawaiic 323 62.6 (55.2, 69.9) 79.7 (73.9, 84.4) 88.9 (83.4, 92.8) 64.2 (51.1, 75.5) 24.7 (11.4, 38.0)b
Idaho 288 54.6 (46.9, 62.3) 73.4 (66.3, 79.5) 74.3 (63.6, 82.6) 71.9 (60.6, 81.0) 2.3 (−11.7, 16.4)
Illinois 572 56.7 (51.1, 62.4) 84.2 (79.4, 88.1) 90.5 (84.5, 94.4) 78.7 (70.0, 85.4) 11.9 (2.8, 20.9)b
Indiana 385 54.0 (47.7, 60.3) 89.7 (85.7, 92.7) 91.4 (85.8, 94.9) 86.9 (79.2, 92.0) 4.5 (−3.2, 12.2)
Iowa 389 68.2 (62.1, 74.2) 78.7 (73.1, 83.3) 83.4 (76.9, 88.3) 70.7 (58.9, 80.3) 12.6 (0.4, 24.8)b
Kansas 309 57.6 (50.7, 64.4) 83.3 (77.8, 87.6) 86.1 (79.2, 90.9) 79.7 (68.9, 87.4) 6.4 (−4.5, 17.3)
Kentucky 299 49.2 (42.0, 56.4) 83.6 (77.9, 88.0) 87.3 (78.5, 92.8) 80.4 (71.4, 87.1) 6.9 (−3.6, 17.4)
Louisiana 301 58.9 (52.0, 65.7) 87.4 (82.2, 91.2) 90.1 (82.8, 94.5) 86.3 (76.2, 92.5) 3.8 (−6.0, 13.6)
Mainec 350 77.9 (72.6, 83.2) 82.3 (77.3, 86.5) 87.7 (82.1, 91.7) 64.1 (50.9, 75.5) 23.5 (10.1, 37.0)b
Marylandc 328 55.4 (47.1, 63.7) 82.5 (75.5, 87.8) 93.1 (84.2, 97.2) 67.0 (53.3, 78.3) 26.2 (12.1, 40.2)b
Massachusetts 396 69.9 (63.8, 76.0) 94.9 (91.5, 96.9) 94.8 (89.3, 97.5) 96.1 (91.1, 98.4) −1.3 (−6.4, 3.7)
Michigan 316 59.4 (52.6, 66.2) 80.1 (74.4, 84.8) 84.2 (76.9, 89.6) 76.7 (66.1, 84.7) 7.6 (−3.7, 18.9)
Minnesotac 386 65.1 (58.6, 71.6) 90.4 (85.7, 93.7) 95.4 (90.1, 97.9) 84.6 (72.7, 91.9) 10.8 (0.7, 20.9)b
Mississippi 295 36.6 (29.9, 43.3) 59.3 (52.6, 65.7) 72.1 (61.2, 80.9) 52.9 (43.9, 61.8) 19.2 (5.8, 32.5)b
Missouri 297 51.2 (43.6, 58.9) 80.9 (75.0, 85.7) 82.7 (73.4, 89.2) 82.0 (73.0, 88.5) 0.6 (−10.4, 11.7)
Montanac 333 59.6 (52.9, 66.2) 84.3 (78.8, 88.6) 87.2 (79.8, 92.2) 82.4 (73.0, 89.0) 4.8 (−5.3, 14.9)
Nebraska 310 59.1 (52.4, 65.7) 85.2 (79.7, 89.4) 89.5 (82.0, 94.1) 82.1 (72.0, 89.1) 7.4 (−2.9, 17.8)
Nevada 352 45.3 (38.8, 51.8) 86.3 (81.4, 90.0) 89.2 (82.9, 93.4) 83.9 (75.6, 89.8) 5.3 (−3.4, 14.0)
New Hampshire 348 70.3 (64.3, 76.3) 94.5 (90.8, 96.8) 95.0 (90.8, 97.3) 92.9 (81.7, 97.5) 2.1 (−5.7, 9.9)
New Jersey 330 59.9 (52.9, 67.0) 84.4 (78.3, 88.9) 85.7 (76.5, 91.7) 84.1 (74.5, 90.5) 1.6 (−9.3, 12.6)
New Mexico 377 56.1 (49.8, 62.5) 85.4 (80.5, 89.3) 86.8 (80.0, 91.6) 84.2 (75.6, 90.2) 2.6 (−6.6, 11.8)
New York 723 62.1 (57.4, 66.9) 89.1 (85.8, 91.6) 93.7 (90.3, 96.0) 82.5 (75.0, 88.1) 11.2 (4.1, 18.2)b
North Carolinac 323 61.3 (54.6, 68.0) 87.9 (83.1, 91.4) 89.1 (82.0, 93.6) 84.6 (76.0, 90.5) 4.5 (−4.6, 13.6)
North Dakotac 351 60.2 (53.3, 67.2) 94.3 (90.5, 96.6) 97.5 (93.8, 99.0) 91.2 (81.2, 96.1) 6.3 (−1.1, 13.6)
Ohio 337 59.6 (53.0, 66.2) 82.2 (76.6, 86.8) 84.9 (77.0, 90.5) 78.2 (68.0, 85.8) 6.7 (−4.4, 17.9)
Oklahoma 439 49.3 (43.4, 55.1) 76.4 (71.1, 81.0) 79.2 (71.4, 85.3) 74.3 (66.3, 81.0) 4.9 (−5.3, 15.0)
Oregon 384 66.1 (60.1, 72.0) 84.9 (79.8, 88.8) 89.1 (83.4, 93.0) 76.2 (65.0, 84.7) 12.9 (1.9, 23.9)b
Pennsylvania 764 66.0 (60.2, 71.9) 89.8 (85.8, 92.8) 93.0 (88.9, 95.6) 84.0 (73.9, 90.7) 9.0 (0.1, 17.9)b
Rhode Island 317 71.7 (65.4, 77.9) 95.5 (91.6, 97.6) 94.5 (88.8, 97.4) 96.4 (88.2, 99.0) −1.9 (−7.8, 4.1)
South Carolina 316 51.6 (44.1, 59.1) 71.0 (64.1, 77.0) 76.1 (66.3, 83.8) 67.7 (56.9, 76.9) 8.4 (−5.0, 21.8)
South Dakotac 307 56.8 (49.9, 63.7) 69.4 (62.8, 75.3) 76.4 (67.4, 83.5) 59.4 (48.6, 69.4) 17.0 (3.7, 30.3)b
Tennessee 313 57.0 (50.1, 63.8) 78.7 (72.9, 83.6) 80.3 (71.9, 86.6) 75.7 (65.0, 83.9) 4.6 (−7.4, 16.5)
Texas 1,202 48.5 (43.2, 53.7) 84.3 (80.4, 87.6) 90.0 (85.7, 93.1) 81.3 (74.9, 86.3) 8.8 (2.0, 15.5)
Utah 330 51.5 (44.7, 58.3) 84.2 (78.5, 88.6) 92.3 (87.4, 95.4) 80.2 (69.9, 87.7) 12.1 (2.4, 21.7)b
Vermont 333 76.6 (70.5, 82.8) 91.6 (87.1, 94.6) 95.5 (90.8, 97.9) 81.1 (65.8, 90.6) 14.4 (1.6, 27.1)b
Virginia 309 57.1 (48.0, 66.2) 82.4 (74.7, 88.1) 82.5 (70.6, 90.2) 84.5 (74.1, 91.3) −2.1 (−14.9, 10.8)
Washington 382 68.6 (62.1, 75.1) 85.1 (79.5, 89.4) 90.0 (83.5, 94.2) 83.6 (70.3, 91.7) 6.4 (−5.4, 18.2)
West Virginia 338 54.4 (47.7, 61.2) 75.7 (69.6, 80.9) 78.5 (69.9, 85.1) 69.4 (59.2, 78.0) 9.1 (−3.1, 21.3)
Wisconsin 338 65.9 (59.4, 72.4) 89.1 (84.1, 92.6) 91.3 (85.3, 95.0) 87.3 (75.8, 93.7) 4.1 (−5.8, 14.0)
Wyoming 331 50.4 (43.8, 57.1) 91.4 (87.8, 94.1) 92.9 (88.0, 95.9) 92.7 (86.8, 96.1) 0.2 (−5.7, 6.1)
Median 57.6 84.2 88.6 81.2 7.2
Range 36.6, 77.9 59.3, 95.5 72.1, 97.5 52.9, 96.4 −2.1, 26.2
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Note: Boldface indicates statistical significance (p < 0.05)

a

Coverage difference between with and without provider recommendation.

b

p <0.05 comparing with and without provider recommendation.

c

States without middle school Tdap vaccination requirement as of 2013.

Tdap, tetanus, diphtheria, and acellular pertussis.

DISCUSSION

The findings indicate that Tdap coverage was significantly higher among adolescents with a provider recommendation compared with those without a provider recommendation. Provider recommendation was associated with higher Tdap coverage across many demographic and access to care factors and 17 states. To the authors’ knowledge, this is the first study to examine the association between provider recommendation and Tdap vaccination among adolescents. Although the impact of provider recommendation on Tdap vaccination was not reported previously, the impact of provider recommendation on other vaccinations was documented. One study showed that hepatitis A vaccination coverage was 86.9% among adolescents with a provider recommendation compared with those without a provider recommendation (65.5%).6 Another study indicated that human papillomavirus vaccination coverage (one or more doses) was 58.3% among adolescents with a provider recommendation compared with those without a provider recommendation (20.7%).13 Recommendations from providers increase parental acceptance of vaccination, and parents change their minds about delaying and refusing vaccines because of information or assurances from healthcare providers.14,15

Provider recommendations for vaccination are strongly associated with a patient’s decision to get vaccinated. Studies have consistently shown that provider recommendation is the strongest predictor of vaccination.6–9 However, the present study showed that about 43% of parents of adolescents reported not receiving a provider recommendation for the vaccine. Providers should strongly recommend vaccines to parents and adolescents. Parents usually trust physicians’ opinions more than anyone else’s when it comes to vaccinations.9 Providers should use every opportunity to vaccinate adolescent patients; review medical records to assess vaccination status when they see adolescents for sick visits and sports physicals; use patient reminder and recall systems (such as automated postcards, phone calls, and text messages); educate parents about the diseases that can be prevented by adolescent vaccines as parents may know very little about pertussis; and implement policies for standing orders so that patients can receive vaccines without a physician examination or individual physician order.9,16–18 Additionally, high coverage can be achieved even without provider recommendation: Overall, coverage is 80% among adolescents without a provider recommendation. Several reasons that may partially account for why coverage is relatively high among those without a provider recommendation included the following: the parent forgot about recommendation; vaccination was recommended and offered but the parent did not interpret the interaction as a recommendation; and the parent asked for the vaccine (e.g., to comply with state immunization pre-matriculation requirements) so a provider recommendation was not needed.

This study showed that having more physician contacts in the past 12 months and having a well-child visit at age 11–12 years were independently associated with a higher level of Tdap vaccination. People who have more physician contacts may have more opportunities to discuss their vaccination status and receive vaccination. But, for many adolescents, the provider visits in the last 12 months might not be the times they would have received Tdap vaccination (which probably occurred at age 11 or 12 years, whereas the sample was adolescents aged 13–17 years). The Advisory Committee on Immunization Practices and partner organizations, including the American Academy of Pediatrics, American Medical Association, and Society for Adolescent Medicine, recommend a well-child visit for children aged 11–12 years to receive recommended vaccinations and indicated preventive services such as vaccinations required to attend middle school.7,19,20 Even though the well-child visit for children aged 11–12 years provides a good opportunity to discuss vaccination status and receive vaccinations, based on this study, only 40.2% of adolescents had a well-child visit at age 11–12 years. Efforts are needed to increase preventive healthcare utilization, especially at age 11–12 years, so that preteens can receive recommended vaccinations and other preventive services. In addition, providers should be encouraged to review and, if necessary, administer recommended adolescent vaccinations at all healthcare visits, in addition to the preteen visit at age 11–12 years, to prevent missed opportunities for vaccination.

Overall, Tdap vaccination coverage among adolescents aged 13–17 years in 2013 was 84.9%. Tdap vaccination coverage among adolescents aged 13–17 years has substantially increased since vaccination coverage was first assessed by NIS-Teen in 2006 (10.8%).21 Tdap vaccination coverage then increased from 30.4% in 2007 to 84.9% in 2013.16–19 Tdap vaccination coverage among adolescents could be compared with that of other vaccines that have also been recommended for adolescents since 2005–2006. Human papillomavirus vaccination coverage among female adolescents increased from 25.1% in 2007 to 57.3% in 2013,21–24 and prevalence of provider recommendation for human papillomavirus vaccination among female adolescents was 68.9% in 2013 (CDC unpublished data). Quadrivalent meningococcal conjugate vaccine coverage increased from 22.4% in 2007 to 77.8% in 2013,21–24 and prevalence of provider recommendation for this vaccine was 36.1% in 2013 (CDC unpublished data). As the vaccination program becomes more mature, coverage could be increased further.21–24 The providers’ role is important for improving vaccination coverage after Advisory Committee on Immunization Practices recommendations for adolescents are made. Providers should strongly recommend adolescent vaccines to their parents and use every opportunity to assess vaccination status and vaccinate adolescent patients.

Substantial differences in coverage among states and regions were observed for Tdap vaccination among adolescents. Variation in state coverage could be due to differing medical care delivery infrastructure, socioeconomic factors, state laws, effectiveness of state and local immunization programs, population attitudes toward vaccinations, immunization resources, reimbursement for vaccines, vaccine administration, variations in prevalence of receipt of provider recommendation for Tdap, and other factors.12,25–35 Assessing local, state, and national vaccination programs is necessary for evaluating progress. For example, state-level comparisons may aid in designing tailored intervention programs and sharing best practices. Some states achieved very high coverage, and states with low prevalence of provider recommendation and lower Tdap coverage may particularly benefit from provider-based interventions such as provider assessment and feedback, provider reminders, and a standing orders program.

Forty states have middle school requirements for Tdap vaccination as of 2013.12 Pertussis outbreaks may occur in middle and high schools and can be highly disruptive and costly to schools and health departments.36 The findings from this study showed that among 11 states without a middle school vaccination requirement, eight states had lower Tdap vaccination coverage than national coverage though only coverage in South Dakota was significantly lower than national coverage. Previous studies also indicated that middle school entry requirements have helped increase coverage for some vaccinations.37–39

Limitations

The findings of this study are subject to several limitations. First, household response rates were 51.1% (landline households) and 23.3% (cell phone households), respectively. Only 59.5% (landline) and 54.5% (cell phone) of completed household interviews also had adequate provider-reported vaccination data. Some bias may remain after weighting adjustments designed to mitigate potential bias from incomplete data from the sample frame and non-response.40–43 Second, some provider-reported vaccination histories might not include all received vaccinations (e.g., vaccinations administered in nontraditional settings such as emergency departments) and might have underestimated vaccination coverage. Finally, reporting of provider recommendation by parents is subject to recall bias if parents did not accurately remember whether or not a recommendation had occurred, particularly parents of older adolescents who had been vaccinated years earlier.

CONCLUSIONS

The current study indicated that Tdap coverage was significantly higher among adolescents with a provider recommendation (88.6%) compared with those without a provider recommendation (80.5%). However, 43% of parents of adolescents did not receive a provider recommendation. Higher coverage can be achieved given that very high coverage was observed in some states and subgroups. For example, Tdap vaccination coverage was >90% among six states and >93% among those with a well-child visit. To further improve Tdap vaccination coverage, vaccine education efforts should target healthcare providers to increase rates of provider recommendation for Tdap. Additionally, evidence-based strategies such as standing orders and provider reminders alone or health systems interventions in combination should be taken to further improve Tdap vaccination coverage. Providers and parents should use every healthcare visit, whether for health problems, well-checks, or physicals for sports, school, or camp, as an opportunity to review adolescents’ vaccination histories and ensure that every adolescent receives Tdap and other recommended vaccines.44,45 Additionally, to increase Tdap coverage, intervention programs should be particularly targeted to the demographic and access to care groups where vaccination coverage was low based on this study. Provider-based interventions such as provider assessment and feedback, provider reminders, and standing orders programs should be enhanced for states with low prevalence of provider recommendation and lower Tdap coverage. State programs are encouraged by CDC to promote adolescent vaccinations within their communities by increasing awareness about the importance and benefits of adolescent vaccination. Federal, state, and local governments and community partners should collaborate to further improve vaccination coverage among adolescents.

Acknowledgments

We thank James A. Singleton and Stacie M. Greby for their thoughtful review of the manuscript.

The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Footnotes

No financial disclosures were reported by the authors of this paper.

References

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