B R I E F R E P O R T
Health Disparities in Human
Papillomavirus Vaccine Coverage:
Trends Analysis From the National
Immunization Survey–Teen, 2008–
Robert A. Bednarczyk,1,2Eileen A. Curran,1Walter A. Orenstein,3,4
and Saad B. Omer1,2,3,4
1Rollins School of Public Health, Emory University;2Center for Health Research–
Southeast, Kaiser Permanente Georgia;3Emory Vaccine Center and4School of
Medicine, Emory University, Atlanta, Georgia
Adolescent uptake of human papillomavirus (HPV) vaccine
remains low. We evaluated HPV vaccine uptake patterns
over 2008–2011 by race/ethnicity, poverty status, and the
combination of race/ethnicity and poverty status, utilizing
National Immunization Survey–Teen data. Minority and
below-poverty adolescents consistently had higher series ini-
tiation than white and above-poverty adolescents.
care disparities; poverty.
HPV vaccines; adolescent; vaccination; health-
Since 2007, the US Centers for Disease Control and Prevention
(CDC) has annually estimated adolescent (ages 13–17) immu-
nization coverage, through the National Immunization Survey–
Teen (NIS-Teen). These reports have documented adolescent
immunization coverage successes (eg, rapid increases in uptake of
new vaccines, such as tetanus and diphtheria toxoids, acellular
pertussis vaccine [Tdap], and quadrivalent meningococcal conju-
gate vaccine [MCV4]) as well as remaining challenges (eg, cover-
age levels below Healthy People 2020 goals). Compared to more
rapid increases in Tdap and MCV4 coverage since 2008, lower
HPV vaccine uptake has been an intractable problem [1–4].
In these reports, the CDC has highlighted atypical demo-
graphic patterns in HPV vaccine series initiation, with HPV
vaccine series initiation higher among Hispanic and black teens
compared to white teens, and among girls below the poverty
line, compared to those at or above the poverty line (hereafter
“above poverty”) [1–4]. However, examining vaccination pat-
terns among these characteristics independently may miss
more nuanced health disparities. It has been postulated that
“racial disparities should not be analyzed without simultane-
ously considering the contribution of class disparities . . .
Moreover, this approach suggests that class-based health dis-
parities should never be analyzed without simultaneously con-
sidering the contribution of race” . We are not aware of
adolescent vaccine uptake analyses taking both of these factors
into account simultaneously over multiple years.
Understanding multiyear patterns in these national estimates
is important to mitigating barriers to greater HPV vaccine
uptake. We conducted this evaluation to (1) assess HPV vaccine
uptake by the combination of race/ethnicity and poverty status
and (2) conduct a multiyear analysis of HPV vaccine uptake,
using 4 years of data (2008 through 2011 NIS-Teen cohorts).
Public use data files for the 2008 through 2011 NIS-Teen were
available from the CDC . The NIS-Teen utilizes random
digit dialing to identify households with 13- to 17-year-old ad-
olescents, for whom routine vaccine coverage is measured and
verified with the adolescent’s healthcare provider [6, 7]. We
evaluated uptake of Tdap, MCV4, and HPV vaccine among
female adolescents, by race/ethnicity, poverty status, and the
combination of race/ethnicity and poverty status. Socio-
demographic categories were self-reported, and classified as
non-Hispanic white, non-Hispanic black, Hispanic, and other
non-Hispanic, with poverty status assessed by comparing re-
ported household income to US Census poverty levels . This
analysis was conducted only for female adolescents, for all vac-
cines, to provide the most consistent comparison.
We compared vaccine uptake over the period between 2008
and 2011, and used regression analysis to compute the average
annual increase for a 1-year change in vaccine uptake by the so-
ciodemographic characteristics under study. Analyses were
conducted in SAS version 9.3 (SAS Institute, Cary, North Caro-
lina), using the survey method–specific procedures PROC
SURVEYMEANS and PROC SURVEYREG, with weights as
provided in the NIS-Teen datasets. Sex- and sociodemo-
graphic-level specific values were computed using domain anal-
ysis in the survey procedures.
Received 29 May 2013; accepted 17 October 2013; electronically published 25 October 2013.
Correspondence: Robert A. Bednarczyk, PhD, Hubert Department of Global Health, Rollins
School of Public Health, CNR, 7020-F, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322
Clinical Infectious Diseases 2014;58(2):238–41
© The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@
238 • CID 2014:58 (15 January) • BRIEF REPORT
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Because this analysis utilized existing previously collected
and freely available public data, this was considered to be non–
human subjects research and did not require institutional
review board approval.
HPV vaccine series initiation increased by approximately 16
percentage points between 2008 and 2011 (from 37.2% to
53%). Over the same period, MCV4 uptake increased by 26.5
percentage points (from 43.1% to 69.6%) and Tdap uptake in-
creased by 37.3 percentage points (from 41.0% to 78.3%).
Coverage by Poverty Status
Since 2008, HPV vaccine series initiation for below-poverty ad-
olescents has been consistently and stably higher than for
above-poverty adolescents (Supplementary Figure 1; Table 1).
The initial difference by poverty status (10.6% higher in below-
poverty adolescents in 2008) persisted over the study period
(12.0% higher in below-poverty adolescents in 2011) (Table 1).
HPV vaccine is the only routinely recommended adolescent
vaccine to exhibit this pattern (Supplementary Figure 1). Series
completion was initially low among below poverty adolescents
(15% in 2008, compared to 19% for above poverty), but
exceeded that of above-poverty adolescents by 2011 (39% vs
33%) (Supplementary Table 1).
Coverage by Race/Ethnicity
HPV vaccine series initiation was consistently highest for His-
panic adolescents, followed by black adolescents, with lowest
uptake among white adolescents (Supplementary Figure 1;
Table 1). Hispanics had both the highest initial coverage
(44.4%) and the greatest increase by 2011 (increase of 20.6 per-
centage points). The average rate of increase for Hispanics was
nearly double that for whites (7.0% vs 3.8% average annual in-
crease, respectively) over this period (Table 1). This pattern is
similar to that for MCV4 coverage (Supplementary Figure 1).
For Tdap, white and Hispanic adolescents had nearly identical
vaccine coverage, and black adolescents had slightly, but consis-
tently, lower Tdap coverage (Supplementary Figure 1). More
than 40% of Hispanic females completed the 3-dose series by
2011, whereas all other race/ethnicity groups had completion
percentages ranging from 32% to 35% (Supplementary Table).
Coverage by Race/Ethnicity and Poverty Status
By 2011, above-poverty non-Hispanic white females had the
lowest HPV vaccine series initiation (46.7%), an increase of
only 11% from 2008. Below-poverty Hispanics had the highest
coverage in 2011 (69.2%), following their high initial coverage
Poverty Status, Race/Ethnicity, and the Combination of Race/Ethnicity and Poverty Status, United States, NIS-Teen, 2008–2011
Uptake of at Least 1 Dose of Human Papillomavirus Vaccine Among Adolescent (Aged 13–17) Females, in Aggregate, and by
% 95% CI% 95% CI
Above poverty level
Below poverty level
NH white, above poverty
NH white, below poverty
NH black, above poverty
NH black, below poverty
Hispanic, above poverty
Hispanic, below poverty
NH other, above poverty
NH other, below poverty
Abbreviations: CI, confidence interval; NH, non-Hispanic; NIS-Teen, National Immunization Survey–Teen.
aAs estimated through PROC SURVEYREG.
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in 2008 (53%). For every race/ethnicity group, coverage was
higher among below-poverty adolescents by 2011 (Table 1).
There was less variability in series completion by the combi-
nation of race/ethnicity and poverty status; below-poverty His-
panics again had the highest overall coverage (45%). HPV
vaccine series completion was higher for below-poverty adoles-
cents in the non-Hispanic black, non-Hispanic other, and His-
panic groups compared to their above-poverty peers. Series
completion was the same (33%) for both above- and below-
poverty white adolescents (Supplementary Table 1), following a
larger increase in series completion among below-poverty
whites (from 12% to 33%) compared to above-poverty whites
(from 20% to 33%) (Supplementary Table 1).
We found that national estimates of HPV vaccine series initia-
tion by adolescent girls demonstrate a consistent pattern of
higher HPV vaccine uptake among adolescents below the
federal poverty level, compared to those above the poverty level.
This finding is unique to the HPV vaccine, and persisted across
racial and ethnic categories.
The finding of lowest HPV vaccination among above-
poverty white adolescents needs further evaluation. This may
be related to findings of greater active refusal of all childhood
vaccines among mothers who were white, were college educat-
ed, and had higher incomes . It is possible that HPV vaccine
is more often refused by above-poverty whites because of
greater access to routine cervical screening, leading to a lowered
perceived need for the HPV vaccine.
Medically underserved populations with less access to
routine care, especially racial and ethnic minorities, have higher
rates of cervical cancer [9,10].Maternal experiences with HPV-
related disease have been associated with greater willingness to
vaccinate daughters against HPV .A recent study identified
increasing safety concerns about the HPV vaccine, relative to
those of Tdap and MCV4, as a contributor to lower HPV
vaccine uptake ; it is possible that greater awareness of
HPV-related diseases in some populations may overcome
vaccine safety concerns. Continued research is needed on soci-
ocultural impacts of disease awareness within the context of
sociodemographic information, including more in-depth quali-
tative assessments on the interactions of these factors.
Given the high cost of the HPV vaccine, it has been hypothe-
sized that the Vaccines for Children program may have a
greater impact on HPV vaccine uptake among traditionally un-
derserved populations [1–4]. However, health insurance plans
provide first-dollar coverage and/or have no annual deductible
requirements for HPV vaccine at levels consistent with other
routinely recommended adolescent vaccines , indicating
little difference in cost-sharing for adolescent vaccines among
privately insured adolescents.
Whereas there are few states with HPV vaccine middle
school entry requirements, 30 states have middle school Tdap
requirements and 22 states have MCV4 requirements .
However, even with more states having middle school entry
vaccination requirements for Tdap than for MCV4, Tdap cov-
erage exceeded that of MCV4 by only 8% by 2011.
This evaluation is subject to some limitations. First, because
of relatively small samples of some racial groups (eg, American
Indian/Alaska Native and Asian), we used a 4-level race/ethnic-
ity classification (non-Hispanic white, non-Hispanic black,
Hispanic, non-Hispanic other), which may overlook differences
in other racial groups by poverty status. Future studies specifi-
cally addressing poverty-level disparities among these groups
are needed. This study was focused on the effects of race/eth-
nicity and poverty on adolescent vaccination, and did not
address other factors that can affect HPV vaccination, including
provider recommendation [15,16]. Additional studies are needed
to address the relationship between provider recommendation
and sociodemographic factors. The lack of a SAS procedure for
generalized linear models for complex survey data necessitated
the use of the SURVEYREG procedure to evaluate the average
per-year increase in vaccine coverage, using linear regression.
Although not optimal, this approach will not provide estimates
biased in the same way as logistic regression estimates. Finally,
the available data only spanned 4 years; the 2012 NIS-Teen
public use files were not available at the time of this analysis.
Generally high coverage of Tdap and MCV4 indicates the
potential for high HPV vaccine uptake. Expanded use of de-
tailed surveillance efforts to reach more granular subpopula-
tions of adolescents and greater utilization of multiple years of
data to evaluate consistent disparity patterns are needed to
develop and implement interventions to address disparities in
adolescent immunization coverage.
Supplementary materials are available at Clinical Infectious Diseases online
(http://cid.oxfordjournals.org/). Supplementary materials consist of data
provided by the author that are published to benefit the reader. The posted
materials are not copyedited. The contents of all supplementary data are the
sole responsibility of the authors. Questions or messages regarding errors
should be addressed to the author.
tributed to the authors and not to the National Center for Health Statistics,
which is responsible only for the initial data.
Potential conflicts of interest.
All authors: No potential conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
All analyses, interpretations, or conclusions reached are at-
240 • CID 2014:58 (15 January) • BRIEF REPORT
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