What’s Known
Adolescent vaccination coverage is improving, but gaps
remain between HPV and other adolescent vaccines, and
on-time series completion is especially low.
• Adolescent (13-17 years) HPV vaccine coverage, as
assessed in 2020, has continued to increase in the
United States (75% having received at least 1 HPV
vaccine dose, compared to 72% in 2019; 59% up-
to-date, compared to 54% in 2019), but still trails
coverage of Tdap vaccine (90%) and quadrivalent
meningococcal conjugate vaccine (89%).
1
• A study published in 2019, using the 2016 National
Immunization Survey-Teen data, found that while
60.4% of adolescents had initiated HPV vaccination
by ages 13-17 years, only 15.8% were fully up-to-date
prior to their 13th birthday.
2
• Benchmarks for quality improvement, including
HEDIS measures, assess vaccination at 13 years of age.
3
Initiating HPV vaccination at the rst opportunity (e.g.,
9 years of age) can help achieve these QI goals.
HPV vaccination is recommended for ages 9-12, but specic
recommendations related to age dier by organization.
• The American Academy of Pediatrics and the
American Cancer Society recommend HPV
vaccination between 9-12 years of age.
4,5
• The Advisory Committee on Immunization Practices
recommends starting the HPV vaccine series at 11-12
years of age and indicates that vaccination can be
started as early as 9.
6,7
Implementing HPV vaccination at the earliest
opportunity produces a strong immune response.
• HPV vaccination at younger ages (e.g., less than 15
years) yields higher antibody titers compared to
vaccination later in adolescence, even with a reduced
2-dose schedule.
8,9
HPV Vaccination at 9-12 Years of Age
What’s New
Eorts to improve HPV vaccination at the rst
opportunity help improve overall vaccine uptake.
• Adolescents initiating HPV vaccination at 9-10 years
were more likely to be fully up-to-date by 13.5 years
of age compared to those initiating at 11 to 12 years
(97.5% versus 78%, respectively).
10
• QI initiatives, including changing electronic medical
record prompts to alert providers of the need for HPV
vaccination starting at 9 years rather than 11 years, led
to an 8-fold increase in vaccination prior to 11 years of
age (4.6% to 35.7%).
11
• A provider-focused multi-level intervention
in pediatric oces that agreed to initiate HPV
vaccination at 9-10 years of age resulted in a 13
percentage point increase in vaccination among
9-10-year-olds, which was not only sustained
but increased in the post-intervention period (27
percentage point increase ).
12
• A 2021 survey of over 1,000 U.S. primary care
professionals found that about one-fth (21%) were
routinely recommending the HPV vaccine at age
9-10. Another 48% were somewhat or more willing to
adopt the practice of recommending the HPV vaccine
at age 9.
13
Initiating HPV vaccination at 9-10 years of age is
acceptable to both parents and health care providers.
• Attendance at care visits decreases in older
adolescence. Therefore initiating the series younger
provides more opportunities to complete the vaccine
series on time.
14
For example, this allows providers to
give the two HPV vaccine doses 12 months apart at
annual well-child visits at 9 and 10 years of age, with
Tdap and MCV4 vaccination given at 11 years of age.
• Providers nd conversations are easier as sexual
activity is not a focus.
15
• The opportunity to receive fewer vaccines per visit is
appealing to parents, adolescents, and clinicians.
15,16
APRIL 2022
What’s Next
There are a number of gaps in our ability to widely implement HPV vaccination at the rst opportunity that need to be
addressed.
Data gaps:
• Rather than reporting vaccinations received by a particular age, more granular data analysis (e.g., NIS-Teen, state-
level IIS) by age at vaccination and birth cohorts can better identify missed opportunities for HPV vaccination.
• The impact of the COVID-19 pandemic on adolescent vaccination needs to be better understood. The 2020 NIS-
Teen data
1
did not fully reect the impacts of the COVID-19 pandemic on adolescent vaccination
17
, as adolescents
may have been vaccinated prior to the pandemic but assessed in 2020.
Dissemination and implementation gaps:
• Aside from research-based projects showing vaccination gains with recommendations at 9-10 years, most evidence
of implementation success has been limited in scope. Larger implementation studies are needed.
• For practices having success at bundling HPV, Tdap, and MCV4 at 11 years of age, the bundling eorts should
be continued and supported. Where success has been more dicult to come by, HPV vaccination at the rst
opportunity (e.g., 9 years of age) may be an option to improve coverage.
• Communications tools need to be developed to reassure pediatricians that it is safe and eective to give HPV
vaccine starting at 9 years and that parents are accepting of vaccination at that age.
1. Pingali C, Yankey D, Elam-Evans LD, et al. National, Regional, State, and Selected
Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United
States, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(35):1183-1190.
2. Bednarczyk RA, Ellingson MK, Omer SB. Human Papillomavirus Vaccination Before 13
and 15 Years of Age: Analysis of National Immunization Survey Teen Data. J Infect Dis.
2019;220(5):730-734.
3. Assurance NCfQ. Immunizations for Adolescents (IMA). https://www.ncqa.org/hedis/
measures/immunizations-for-adolescents/. Published 2021. Accessed February 10,
2022.
4. American Cancer Society. Prevent 6 cancers with the HPV vaccine. https://www.
cancer.org/healthy/hpv-vaccine.html. Published 2022. Accessed February 10, 2022.
5. O'Leary S, Nyquist A. Why AAP recommends initiating HPV vaccination as early
as possible. https://publications.aap.org/aapnews/news/14942. Published 2019.
Updated October 4, 2019. Accessed February 10, 2022.
6. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination:
recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep. 2014;63(Rr-05):1-30.
7. Petrosky E, Bocchini JA, Jr., Hariri S, et al. Use of 9-valent human papillomavirus (HPV)
vaccine: updated HPV vaccination recommendations of the advisory committee on
immunization practices. MMWR Morb Mortal Wkly Rep. 2015;64(11):300-304.
8. Dobson SR, McNeil S, Dionne M, et al. Immunogenicity of 2 doses of HPV vaccine in
younger adolescents vs 3 doses in young women: a randomized clinical trial. Jama.
2013;309(17):1793-1802.
The HPV vaccination Roundtable convenes, communicates
with, and catalyzes member organizations to increase HPV
vaccination rates and prevent HPV cancers.
Learn more at hpvroundtable.org.
9. Iversen OE, Miranda MJ, Ulied A, et al. Immunogenicity of the 9-Valent HPV Vaccine
Using 2-Dose Regimens in Girls and Boys vs a 3-Dose Regimen in Women. Jama.
2016;316(22):2411-2421.
10. St Sauver JL, Rutten LJF, Ebbert JO, Jacobson DJ, McGree ME, Jacobson RM. Younger
age at initiation of the human papillomavirus (HPV) vaccination series is associated
with higher rates of on-time completion. Prev Med. 2016;89:327-333.
11. Goleman MJ, Dolce M, Morack J. Quality Improvement Initiative to Improve Human
Papillomavirus Vaccine Initiation at 9 Years of Age. Acad Pediatr. 2018;18(7):769-775.
12. Perkins RB, Legler A, Jansen E, et al. Improving HPV Vaccination Rates: A Stepped-
Wedge Randomized Trial. Pediatrics. 2020;146(1).
13. Kong WY, Huang Q, Thompson P, Grabert BK, Brewer NT, Gilkey MB. Recommending
HPV vaccination at age 9: A national survey of primary care professionals. Academic
Pediatrics. 2022.
14. Nordin JD, Solberg LI, Parker ED. Adolescent primary care visit patterns. Ann Fam
Med. 2010;8(6):511-516.
15. Biancarelli DL, Drainoni ML, Perkins RB. Provider Experience Recommending HPV
Vaccination Before Age 11 Years. J Pediatr. 2020;217:92-97.
16. Healy CM, Montesinos DP, Middleman AB. Parent and provider perspectives
on immunization: are providers overestimating parental concerns? Vaccine.
2014;32(5):579-584.
17. Saxena K, Marden JR, Carias C, et al. Impact of the COVID-19 pandemic on adolescent
vaccinations: projected time to reverse decits in routine adolescent vaccination in
the United States. Curr Med Res Opin. 2021;37(12):2077-2087.
