Christina Dorell, MD, MPH Human Papillomavirus (HPV) Vaccination Coverage in the United States, National Immunization Survey-Teen, 2007-2010 Christina Dorell, MD, MPH Medical Epidemiologist Immunization Services Division 2012 National Immunization Conference Online March 26, 2012 National Center for Immunization & Respiratory Diseases

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

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 13-26 years. Since 2009, the bivalent HPV vaccine could also be given.

Background In 2009, quadrivalent HPV vaccination of males 11-26 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 13-21 years. Males ages 22-26 years may also be vaccinated if desired.

National Immunization Survey-Teen NIS-Teen Conducted since 2006 Random-digit-dialing household survey of parents of adolescents 13-17 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: http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nisteen

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)

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)

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

Tdap,* MCV4,† and HPV§ vaccination estimates among adolescents, 13-17 years, NIS-Teen, United States, 2007-2010 ≥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

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.]

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, 2008-2009. 2011. Pediatrics.128:830-839.

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.

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

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.

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.

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.

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.

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.

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.

Intent to receive HPV vaccine within the next 12 months among unvaccinated females, 13-17 years, by receipt of a provider recommendation, NIS-Teen, United States, 2008-2009

Main parent-reported reasons for intent not to receive the HPV vaccine within the next 12 months among females, 13-17 years, NIS-Teen, United States, 2008-2009 Reasons for not intending to receive the HPV vaccine % (95% CI) Lack of knowledge 19.4 (17.3-21.8) Not needed or not necessary 18.8 (17.0-20.7) Not sexually active 18.3 (16.6-20.2) Did not receive provider recommendation 13.1 (11.6-14.8) Not appropriate age 7.3 (6.2-8.5) Safety concern/side effects 7.3 (6.3-8.5) More information /new vaccine 4.2 (3.5-5.1)

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

Major Findings - Initiation During 2008-2009, 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.

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

Major Findings - Completion Completion of the HPV series were low at 64.0% in 2008-2009. Lower completion among: all races/ethnicities other than white lower household incomes VFC-eligible insured and uninsured when all vaccination received at public facilities

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

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.

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.

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). www.thecommunityguide.org/vaccines/universally/clientoutofpocketcosts.html. Last updated: 1/31/2011. † Guide to Community Preventive Services. Universally recommended vaccinations: immunization information systems and : client reminder & recall systems . www.thecommunityguide.org/vaccines/universally/imminfosystems.html. Last updated: 1/31/2011.

Thank you For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov 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

Additional slides

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

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

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

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.

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

Main Parent-reported Reasons for Females, 13-17 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 (3.2-4.8) Already up-to-date 3.3 (2.7-4.1) Costs 3.2 (2.5-4.2) Child should make decision 1.3 (0.9-2.0) Child fearful 1.2 (0.8-1.9) No doctor or doctor's visit not scheduled 1.1 (0.7-1.7) Other 1.1 (0.9-1.3) Handicapped/Special Needs/Illness 1.0 (0.6-1.7)

Adherence to recommended dosing intervals among females, 13-17 years, who received at least 2 HPV doses, NIS-Teen, United States, 2008-2009a 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, 13-17 years, National Immunization Survey-Teen, 2008-2009. 2012. Vaccine. 30(3):503-505

Adherence to recommended dosing intervals among females, 13-17 years, who received at least 2 HPV doses, NIS-Teen, 2008-2009 Dosing interval Definition of adherence (months) Percent of participants (confidence interval) Early On time Late Doses 1-2b 1-3c 0.1 (0.0-0.3) 63.4 (60.8-65.8) 36.6 (34.1-39.1) Doses 2-3d 3-5e 2.5 (1.9-3.4) 67.5 (65.0-69.9) 30.0 (27.6-32.5) Doses 1-3d 6-7f 4.8 (3.8-5.9) 48.8 (46.0-51.6) 46.4 (43.6-49.3) 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).