The impact of provider recommendation on human papillomavirus vaccine and other adolescent vaccines

Figures & data

Table 1. Patient demographics and percentage of respondents who recalled a provider recommendation for MenACWY, Tdap, and HPV vaccines.^a,b

	2008 (%)	2009 (%)	2010 (%)	2011 (%)	2012 (%)	2013 (%)	2014 (%)	2015 (%)	2016 (%)	2017 (%)	2018 (%)
Age
13	19.2	18.9	19.7	19.5	20.2	19.8	20.1	19.7	19.5	20.0	20.4
14	19.8	20.1	19.4	20.0	19.6	20.4	20.2	20.0	20.0	19.7	19.6
15	21.0	21.9	21.6	20.6	21.2	20.6	19.4	21.0	21.0	21.0	20.4
16	20.5	20.6	20.3	21.1	20.1	21.4	20.7	20.3	20.4	20.8	20.2
17	19.6	18.4	19.1	18.8	18.9	17.7	19.6	19.0	19.1	18.5	19.3
Sex
Male	51.2	51.2	51.2	51.2	51.2	51.2	51.1	51.1	51.1	51.0	51.0
Female	48.8	48.8	48.8	48.8	48.8	48.8	48.9	48.9	48.9	49.0	49.0
Race
Hispanic	18.4	18.6	19.1	20.0	21.8	22.1	22.4	22.8	23.2	23.7	24.2
Non-Hispanic white	60.2	59.9	59.1	57.3	55.0	55.0	54.4	53.5	52.7	52.3	51.9
Non-Hispanic black	15.0	14.3	14.9	14.4	14.1	13.8	14.0	14.0	13.7	13.8	13.7
Non-Hispanic other/multiple race	6.4	7.2	6.9	8.3	9.2	9.1	9.2	9.7	10.3	10.2	10.3
Language
English	89.9	90.3	90.0	88.9	87.6	88.1	86.2	87.4	88.6	85.8	86.1
Spanish	9.0	8.2	8.8	9.3	10.2	10.8	11.8	10.7	8.9	11.8	11.9
Other	1.2	1.6	1.3	1.8	2.3	1.0	2.0	1.9	2.4	2.4	2.0
Poverty Status
Above poverty >75 K	37.1	39.4	37.8	34.0	33.9	36.6	36.2	37.5	38.4	41.1	43.6
Above poverty ≤$75 K	44.8	43.0	41.6	42.4	39.4	39.5	35.3	33.9	34.2	32.0	30.9
Below poverty	18.1	17.6	20.5	23.6	26.7	23.8	23.2	22.6	21.3	20.5	19.4
Census Region
Northeast	17.6	17.6	17.6	17.1	17.0	16.9	16.7	16.6	16.5	16.4	16.2
Midwest	22.1	22.1	22.2	21.9	21.8	21.7	21.7	21.6	21.4	21.3	21.2
South	36.3	36.3	36.5	36.9	37.1	37.5	37.8	38.0	38.3	38.4	38.6
West	24.0	23.9	23.7	24.1	24.1	24.0	23.8	23.8	23.8	23.9	24.0
Number of Children in Household
One	30.5	31.2	31.7	31.8	31.5	37.2	33.2	33.1	33.1	33.5	33.6
Two or three	56.6	56.6	55.9	55.2	55.4	52.7	54.6	54.4	54.7	54.5	54.4
Four or more	12.8	12.2	12.4	13.0	13.2	10.1	12.2	12.5	12.2	12.1	12.0
Respondents Recalling a Provider Recommendation^c
Recommendation of “meningitis shot”	31.2 (29.8, 32.6)	35.6 (34.3, 37.0)	37.9 (36.5, 39.2)	39.3 (38.1, 40.5)	40.3 (39.0, 41.7)	36.2 (34.8, 37.6)
Recommendation of “tetanus booster shot”	48.2 (46.7, 49.8)	50.8 (49.5, 52.2)	51.6 (50.2, 52.9)	51.9 (50.7, 53.1)	54.0 (52.7, 55.4)	57.1 (55.7, 58.6)
Recommendation of “HPV shots” among females	49.2 (47.0, 51.3)	57.0 (55.1, 58.9)	54.9 (53.0, 56.7)	58.8 (57.1, 60.5)	65.3 (63.5, 67.1)	69.5 (67.5, 71.4)	74.2 (72.4, 76.0)	77.2 (75.6, 78.8)	77.4 (75.7, 79.2)	81.8 (80.3, 83.4)	82.3 (81.2, 84.1)
Recommendation of “HPV shots” among males			5.5 (4.7, 6.3)	14.2 (13.1, 15.4)	30.6 (28.9, 32.2)	45.7 (43.7, 47.7)	53.7 (51.8, 55.7)	59.8 (58.0, 61.6)	65.5 (63.7, 67.3)	68.9 (67.1, 70.7)	72.6 (70.8, 74.3)

a. All percentages were estimated while accounting for the complex survey design.

b. Percentages reported are for each year.

c. Estimates and confidence intervals from log-binomial regression models of recommendation of MenACWY, Tdap, and HPV vaccine for males and females show a significant increase from 2008 to 2018.

MenACWY, quadrivalent meningococcal conjugate vaccine; Tdap, Tetanus-diphtheria-acellular pertussis vaccine; HPV, Human papillomavirus.

Table 2. Coverage differences^a [%(95%CI)] for each vaccine

Vaccine	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018
MenACWY	36.9	34.5	27.1	18.0	17.3	15.0
	(33.6, 40.1)	(31.8, 37.1)	(24.7, 29.5)	(15.8, 20.2)	(15.0, 19.6)	(12.6, 17.2)
Tdap	12.0	12.5	11.5	7.6	7.4	7.6
	(8.9, 15.0)	(9.8, 15.1)	(9.1, 13.9)	(5.6, 9.6)	(5.5, 9.2)	(5.4, 9.7)
1HPV Female	39.4	35.3	28.7	26.2	28.9	26.0	33.4	30.4	33.3	26.3	24.4
	(35.4, 43.2)	(31.4, 38.9)	(24.8, 32.3)	(22.6, 29.6)	(24.9, 32.8)	(21.1, 30.5)	(28.8, 37.7)	(25.7, 34.7)	(28.2, 37.8)	(21.0, 31.3)	(19.2, 29.3)
1HPV Male			16.7	32.4	36.5	44.8	44.1	42.1	33.5	30.3	30.4
			(10.5, 22.9)	(27.8, 37.0)	(32.8, 40.1)	(41.1, 48.4)	(40.6, 47.5)	(38.5, 45.5)	(29.5, 37.2)	(25.9, 34.4)	(26.1, 34.4)
3HPV Female	22.0	27.1	23.1	18.7	23.0	21.9	28.2	25.8	27.0	23.0	21.2
	(18.6, 25.2)	(24.2, 29.8)	(19.6, 26.4)	(15.2, 22.0)	(19.2, 26.5)	(17.0, 26.3)	(24.1, 32.0)	(21.2, 29.8)	(22.6, 31.0)	(17.6, 27.7)	(16.6, 25.2)
3HPV Male			0.8	5.8	12.4	20.8	26.1	28.2	24.4	22.3	19.6
			(−0.4, 2.0)	(3.9, 7.6)	(9.6, 15.1)	(17.5, 23.9)	(22.8, 29.2)	(25.1, 31.2)	(20.8, 27.7)	(18.4, 25.8)	(15.6, 23.3)

a. Coverage differences are defined for each vaccine as the difference between the percentages vaccinated of those who recall a provider recommendation and those who do not. These differences are significant if the confidence interval does not include 0.

MenACWY, quadrivalent meningococcal conjugate vaccine; Tdap, Tetanus-diphtheria-acellular pertussis vaccine; HPV, Human papillomavirus.

Figure 1. HPV, MenACWY, and Tdap vaccine coverage by provider recommendation and sex 2008–2018

Table 3. Estimated coverage [%(95%CI)]^a of adolescents for MenACWY, Tdap, and HPV vaccines, 2008–2018

	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018
Overall
MenACWY	42.3	54.4	63.4	71.4	75.0	78.8	80.2	82.4	82.9	85.9	87.2
	(40.9, 43.8)	(53.2, 55.7)	(62.2, 64.7)	(70.4, 72.5)	(73.8, 76.1)	(77.7, 79.9)	(79.1, 81.3)	(81.4, 83.4)	(81.9, 83.9)	(84.9, 86.8)	(86.3, 88.1)
Tdap	40.8	55.6	68.7	78.2	84.6	86.0	87.6	86.4	88.0	88.7	88.9
	(39.3, 42.2)	(54.3, 56.8)	(67.5, 69.8)	(77.2, 79.1)	(83.7, 85.5)	(85.1, 87.0)	(86.7, 88.5)	(85.4, 87.3)	(87.1, 88.9)	(87.8, 89.6)	(88.1, 89.7)
1HPV (females)	37.2	44.3	48.7	53.0	53.9	57.3	60.0	62.8	65.0	68.6	69.9
	(35.1, 39.3)	(42.4, 46.1)	(46.9, 50.5)	(51.4, 54.7)	(52.0, 55.7)	(55.4, 59.2)	(58.1, 61.8)	(61.0, 64.6)	(63.3, 66.8)	(66.9, 70.3)	(68.1, 71.7)
1HPV (males)			1.4	8.3	20.8	34.6	41.7	49.8	56.0	62.6	66.3
			(1.0, 1.7)	(7.3, 9.2)	(19.3, 22.4)	(32.7, 36.5)	(39.9, 43.6)	(48.0, 51.5)	(54.3, 57.7)	(61.0, 64.2)	(64.6, 68.0)
3HPV (females)	17.9	26.7	32.0	34.8	33.4	37.6	39.7	41.9	43.0	43.9	37.9
	(16.3, 19.5)	(25.2, 28.2)	(30.3, 33.6)	(33.2, 36.4)	(31.7, 35.2)	(35.7, 39.6)	(37.8, 41.5)	(40.1, 43.7)	(41.1, 44.8)	(42.0, 45.9)	(36.1, 39.8)
3HPV (males)			0.1	1.3	6.8	13.9	21.6	28.1	31.5	34.8	32.0
			(0.0, 0.1)	(1.0, 1.7)	(5.8, 7.8)	(12.5, 15.3)	(20.0, 23.2)	(26.5, 29.7)	(29.9, 33.1)	(33.2, 36.4)	(30.2, 33.9)
With a Recommendation
MenACWY	67.8	76.2	80.2	81.9	85.0	88.1
	(65.1, 70.4)	(74.1, 78.2)	(78.5, 81.9)	(80.3, 83.5)	(83.5, 86.6)	(86.5, 89.7)
Tdap	47.6	61.5	74.3	81.9	88.5	89.7
	(45.4, 49.7)	(59.6, 63.4)	(72.8, 75.8)	(80.7, 83.1)	(87.4, 89.6)	(88.7, 90.8)
1HPV (females)	57.5	59.4	61.7	63.8	64.3	65.6	69.2	70.8	73.0	73.8	74.3
	(54.6, 60.4)	(57.1, 61.8)	(59.3, 64.1)	(61.8, 65.8)	(62.0, 66.5)	(63.3, 67.8)	(67.2, 71.3)	(68.8, 72.7)	(71.2, 74.8)	(71.9, 75.7)	(72.3, 76.3)
1HPV (males)			17.2	36.1	46.3	59.6	63.4	67.5	68.8	72.5	75.1
			(11.9, 22.5)	(31.8, 40.3)	(43.0, 49.5)	(56.8, 62.4)	(61.0, 65.7)	(65.1, 69.8)	(66.8, 70.9)	(70.6, 74.3)	(73.2, 77.0)
3HPV (females)	29.4	38.4	42.5	42.3	42.0	44.6	47.9	48.9	49.5	48.9	41.2
	(26.6, 32.2)	(36.1, 40.7)	(40.2, 44.8)	(40.2, 44.4)	(39.7, 44.2)	(42.3, 47.0)	(45.6, 50.2)	(46.8, 51.1)	(47.3, 51.7)	(46.7, 51.0)	(39.0, 43.3)
3HPV (males)			0.9	6.3	15.4	25.6	34.4	39.9	40.6	41.7	37.7
			(0.1, 1.6)	(4.7, 7.9)	(13.0, 17.8)	(22.9, 28.4)	(31.8, 37.0)	(37.5, 42.2)	(38.4, 42.7)	(39.7, 43.8)	(35.4, 40.0)
Without a Recommendation
MenACWY	30.9	41.7	53.1	63.9	67.7	73.1
	(29.1, 32.7)	(40.0, 43.4)	(51.3, 54.8)	(62.4, 65.4)	(66.0, 69.4)	(71.5, 74.8)
Tdap	35.6	49.0	62.8	74.3	81.1	82.2
	(33.4, 37.8)	(47.1, 51.0)	(60.9, 64.7)	(72.7, 75.8)	(79.6, 82.6)	(80.3, 84.0)
1HPV (females)	18.1	24.1	33.1	37.6	35.3	39.6	35.8	40.4	39.7	47.4	49.8
	(15.6, 20.6)	(21.3, 27.0)	(30.2, 36.0)	(34.7, 40.5)	(32.1, 38.6)	(35.4, 43.7)	(31.8, 39.8)	(36.3, 44.4)	(35.3, 44.2)	(42.7, 52.2)	(45.2, 54.5)
1HPV (males)			0.5	3.7	9.8	14.8	19.2	25.4	35.4	42.1	44.7
			(0.3, 0.7)	(2.9, 4.4)	(8.3, 11.3)	(12.6, 16.9)	(16.8, 21.7)	(22.8, 28.1)	(32.1, 38.7)	(38.3, 46.0)	(41.0, 48.4)
3HPV (females)	7.4	11.3	19.4	23.6	19.0	22.7	19.7	23.2	22.5	25.9	20.0
	(5.9, 9.0)	(9.8, 12.8)	(17.0, 21.8)	(20.9, 26.2)	(16.2, 21.7)	(18.7, 26.7)	(16.5, 22.7)	(19.4, 26.9)	(18.9, 26.0)	(21.4, 30.4)	(16.3, 23.7)
3HPV (males)			0.03	0.6	3.0	4.9	8.3	11.7	16.2	19.4	18.1
			(0.0, 0.06)	(0.3, 0.8)	(2.1, 4.0)	(3.4, 6.3)	(6.4, 10.2)	(9.8, 13.6)	(13.6, 18.8)	(16.3, 22.6)	(15.0, 21.1)

a. Estimates and 95% confidence intervals obtained from log-binomial regression models. Year to year increases were considered significant when their respective confidence intervals did not overlap.

MenACWY, quadrivalent meningococcal conjugate vaccine; Tdap, Tetanus-diphtheria-acellular pertussis vaccine; HPV, Human papillomavirus.

Table

YEAR	Age Eligible teens with household interviews	Teens with Adequate Provider Data	Final Weighted Frequency for Analysis
2008	30681	17835	21185559
2009	34976	20066	20877592
2010	32429	19257	20562175
2011	38867	23564	20919411
2012	31792	19199	20787057
2013	32596	18264	20811908
2014	38047	21057	20842714
2015	43926	22214	20819526
2016	41994	20880	20827203
2017	43591	20949	20833181
2018	38706	18700	20795755
Total	407605	221985	229262081

Table

Survey Year	Resolution Rate (%)	Screener Completion Rate (%)	Interview Completion Rate (%)	CASRO Response Rate (%)	Teens with Adequate Provider Data (%)
2008	82.2	83.8	85.2	58.7	58.1
2009	82.7	85.0	82.5	58.0	57.4
2010	83.1	85.4	81.6	57.9	59.4
2011	82.9	84.7	81.5	57.2	61.5
2012	84.0	84.9	77.2	55.1	62.0
2013	83.5	86.1	71.1	51.1	59.5
2014	82.6	87.2	83.8	60.3	57.1
2015	82.2	84.4	81.3	56.4	53.4
2016	82.0	83.2	81.3	55.5	53.9
2017	81.1	78.9	80.5	51.5	53.6

Table

Survey Year	Resolution Rate (%)	Screener Completion Rate (%)	Interview Completion Rate (%)	CASRO Response Rate (%)	Teens with Adequate Provider Data (%)
2011	46.9	70.2	68.0	22.4	54.6
2012	52.0	70.6	64.0	23.6	56.4
2013	53.9	73.1	59.1	23.3	54.5
2014	58.9	72.9	72.7	31.2	52.3
2015	56.6	73.4	71.7	29.8	48.9
2016	54.4	76.8	70.7	29.5	47.4
2017	43.1	77.1	70.9	23.5	47.1
2018	40.9	79.2	71.9	23.3	48.3