COVID-19 Affected Adolescent Vaccination Coverage, Heavily Impacted Rural Adolescents


The pandemic may have both widened the vaccination coverage gap between rural and urban adolescents and affected vaccination coverage in general.

Standard vaccinations for conditions excluding COVID-19 were significantly lower for adolescents in rural areas than for those within metropolitan statistical areas (MSAs), a recent Centers for Disease Control and Prevention (CDC) report found. The report also noted a decrease in coverage for quadrivalent meningococcal conjugate (MenACWY) and acellular pertussis (Tdap) vaccines in adolescents born in 2008—a year marking the earliest qualified adolescents in CDC data—compared to previous years.

The vaccination coverage disparity between MSA and non-MSA adolescents was most pronounced for MenACWY, HPV, and Hepatitis A. The disparities and decreases in coverage for Tdap and MenACWY were assessed by CDC researchers led by Cassandra Pingali, MPH, MS.

Pingali and colleagues noted that the CDC’s Advisory Committee on Immunization Practices (ACIP) recommends the following regular vaccinations for those aged 11-12:

  • Tetanus
  • Diphtheria
  • Tdap
  • MenACWY
  • Human papillomavirus or HPV

The investigators added that a booster of MenACWY is also recommended for those aged 16, and adolescents aged 16-23 may also receive a serogroup B meningococcal vaccine, or MenB series. Further vaccines are recommended for children whose vaccinations are not updated, including mumps, measles, hepatitis A and B, rubella vaccine, and varicella vaccine.

“As more adolescents who were due for routine vaccinations during the pandemic age into the (National Immunization Survey-Teen) sample, the full impact of the pandemic can be assessed,” they wrote. “Providers should review vaccination records to ensure that adolescents are current with all recommended vaccinations.”

The researchers saw a review of vaccination coverage data during the COVID-19 pandemic as important for health care providers to continue to keep adolescents updated on their vaccines and figuring out what might contribute to decreases in coverage.

Research and Methods

Investigators drew data for 18,002 adolescents ages 13-17 from the 2021 National Immunization Survey-Teen (NIS-Teen), previously analyzed by the CDC. NIS-Teen is a yearly telephone survey that assesses vaccine coverage among this age group across the country, with records accessed by care providers with the permission of parents and guardians of the adolescents being surveyed.

The investigators found that the Council of American Survey Research Organizations response rate was 21.0%, with 41.2% of adolescents with finished surveys having adequate health care provider information. They used t-tests to compare differences in vaccination coverage between 2021 and 2020, further examining differences among sociodemographic groups. The researchers considered those with a P value of <.05 as statistically significant.

The researchers examined vaccination coverage by age 12 in children born in 2008—as they would have reached 12 by 2020—in order to discover any effects of the COVID-19 pandemic on vaccines for MenACWY, HPV, and Tdap. These children’s data were then compared to that of those born in 2007, who would have reached age 12 by 2019.

Both these groups’ respective data by the time they reached age 13 was compared to those born in 2006. The investigators used SAS-callable SUDAAN to conduct their analyses, with information later reviewed through the CDC.

Study Results

The results of this investigation into NIS-Teen data found that vaccination coverage, for the most part, either increased or remained the same. Nevertheless, the analysis also yielded several causes for concern among the research team.

Vaccination coverage stayed high for adolescents in 2021 with ≥1 dose of MenACWY and ≥1 dose of Tdap, at about 89% for both vaccines, compared to 2020 rates. Between 2020 and 2021, there were also increases in coverage with ≥2 MenACWY doses among adolescents aged 17 years, from 54.4% to 60.0%. The investigators also found that coverage for ≥1 dose of HPV vaccine increased from 75.1% to 76.9%. Additionally, they reported that the percentage of adolescents up to date with HPV vaccination increased from 58.6% to 61.7%. They found that ≥1 HPV vaccination coverage remained the same among children and adolescents who reached age 12 or 13 during the pandemic and those 1 year older.

The investigators found 2 main decreases in overall coverage: ≥1 Tdap dose was 4.1 percentage points less likely among children who reached age 12 years during the pandemic, and ≥1 MenACWY dose for those aged 13 during the pandemic was 5.1 points lower than the percentage of those who had reached 13 by the previous year. The other major finding from the NIS-Teen data was that coverage for MenACWY, HPV vaccine, and ≥2 HepA dose was lower among those living in nonmetropolitan statistical areas, or non-MSAs, than among those living in MSAs.

“Achieving and maintaining high vaccination coverage levels for adolescents will ensure they have protection from serious and sometimes life-threatening vaccine-preventable diseases,” they wrote. “To help adolescents catch up on missed vaccinations, health care providers can identify those who have fallen behind on receiving recommended vaccinations and remind families to schedule an appointment.”

The investigators added that an assessment of patients’ vaccination records may be crucial for health care providers to ensure that children and adolescents remain up to date with each of their recommended vaccines. They recommend the use of resources available online to help delve into vaccination information with parents and patients, which can be found at the CDC website.

The research letter, “National Vaccination Coverage Among Adolescents Aged 13–17 Years — National Immunization Survey-Teen, United States, 2021,” was published online by CDC MMWR.

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