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New data on vaccination rates among U.S. teenagers provide some heartening news — but also pose a bit of a mystery.

The report, from the Centers for Disease Control and Prevention, shows parents of teenagers are in the main following the CDC’s advice and keeping their children up to date on vaccines that should be administered in the early teens.

But the 2016 survey revealed big differences in the rates of teenagers who are vaccinated with some but not all recommended vaccines, depending on whether they live in cities or more rural locations. And that fact is puzzling the CDC scientists who analyzed the data, published Thursday in the CDC journal Morbidity and Mortality Weekly Report.


Both rural and urban kids in large numbers were vaccinated against tetanus, diphtheria, and pertussis —a combined vaccine known as Tdap. In fact, 88 percent of teens received that vaccination, with nearly equal uptake rates among urban and rural adolescents.

But the vaccination rate against human papillomavirus, or HPV, was 16 percentage points lower in rural areas than urban areas. These sexually transmitted viruses can cause a number of cancers. And though one might be tempted to assume that rural parents were less inclined to vaccinate their children against a sexually transmitted virus, it was not the only kind of vaccine for which there was a stark rural-urban divide. The rate of rural teens who received the recommended first dose (of two) of vaccine against meningococcus, which can cause fatal meningitis, was nearly 10 percentage points lower than it was for urban teens.


The senior author of the article said the CDC isn’t sure what’s going on, but it wants to figure it out.

“It’s an area we’re definitely going to be looking into this year to better understand what might be contributing to those results,” said Shannon Stokley, associate director for science in CDC’s immunization services division.

The data were drawn from the 2016 National Immunization Survey-Teen, which focused on vaccination behavior among nearly 20,500 adolescents 13 to 17 years old. The survey is conducted annually.

Stokley said cost is probably not the reason why some rural parents are getting their children immunized with Tdap vaccine, but not HPV or meningococcus. The Affordable Care Act mandates that private insurance cover vaccination costs, and children in low-income families can get free vaccines through the federal Vaccines for Children program.

“Most children are covered, either through insurance or through the VFC program. Even when we’ve interviewed parents cost has not been an issue that has come up as a barrier,” she said. “I’m not sure at this time if we have a leading hypothesis of what’s behind this. But it’s something we want to get to the bottom of and understand.”
Though the HPV vaccine is highly effective, it was first recommended only for girls; in 2011, the CDC recommended it for boys as well.

Public health officials had thought a vaccine that protected against cancers — cervical, anal, and others — would be in big demand, but some parents worried it would be viewed by teenagers as a license to have sex.

Over the last decade, however, HPV vaccination rates have risen. The 2016 data show that about 60 percent of teens get at least one of the two recommended doses of HPV vaccine.

“HPV vaccination is the new norm for boys and girls in the United States,” said Noel Brewer, a professor of health behavior at the University of North Carolina who was not involved in the CDC study. “The majority of parents are getting HPV for their kids. That’s important.”

Also important: The 2016 data show that the gap is closing between the number of girls and boys who are vaccinated. “We’re making a lot of progress with the boys and actually getting very close to where we are with girls. And so that’s really exciting to see,” Stokley said.

Research that Brewer and others have conducted shows that the way doctors approach the issue of HPV vaccination influences whether parents will agree to let their kids get the shots. Firm recommendations that it’s time to get Tdap, HPV, and meningococcus vaccines — messages that convey that the doctor strongly urges all these vaccines — have been shown to result in more agreement from parents.

Conversely, the research shows that doctors who anticipate that parents might object to HPV vaccination and as a result approach the parents with uncertainty actually underscore parental concerns in a way that leads to lower acceptance rates.

Brewer, who heads a national HPV vaccination roundtable for the American Cancer Society, has a theory on why there’s a difference between urban and rural HPV and meningococcal vaccination rates. If he’s right, it’s not because rural doctors aren’t promoting them hard enough. It may be because some urban doctors are working extra hard.

Brewer thinks some urban doctors may more assertively recommend all available and free preventative health care options to children from low-income families when they see them because they know these kids — whose families may not have health insurance — will only infrequently see doctors. In other words, the doctors assume each encounter may be the only chance to administer recommended vaccinations, and they urge parents to accept them.

Delving into what’s happening will help public health officials devise more effective advice for all doctors on how to persuade parents to give their teenagers the full complement of recommended vaccinations, Stokley said. Part of the goal is to get more of the teenagers who have received one shot of HPV vaccine back to get the second dose. (Three doses are recommended if teenagers only begin the course of immunizations when they are 15 or older.)

“We’re really encouraged to see that over 60 percent have started the series,” said Stokley. “And we need to work to get the adolescents back in for the remaining doses.”

  • This is anecdotal, of course, but coming from a rural area, the fact that the researchers were confused about this seems to me to be a lack of empathy about how much harder it can be to get to the doctor in rural areas. Tdap is usually given when kids are younger and more likely to have to be at the doctor. When I got older and less prone to getting sick, I went about 7 years without going to the doctor because the offices were far away, those that were accessible were Urgent Care places that didn’t have my vaccination record, it was hard to find transportation, and I just didn’t know those vaccinations were recommended. When I moved to the city for college I actually went to the doctor and immediately got the recommended vaccines. I don’t think I was alone in this, though I don’t have statistics to back me up. Something to consider.

  • Hopefully, the rate of vaccination will continue to decline !!! Given the ingredients in HPV !!! When you mess with crossing the blood-brain barrier & put aborted fetal cells in a vaccine, WHO IS THAT VACCINE REALLY GOOD FOR ???!!! I’ll tell you the answer absolutely NO ONE !!!!!! Big Pharma & the CDC need to come forward & tell the public about ALL the CRIPPLED & DEAD CHILDREN from the HPV VACCINE !!!! They all need to be IMPRISONED !!!! For their ENTIRE LIVES !!!! I don’t know how they sleep at all, KNOWINGLY, INJURING & KILLING OUR CHILDREN !!! They think they have absolutely NO ONE to answer, BUT ONE DAY EACH & EVERYONE OF THEM WILL ANSWER TO GOD !!!!! Where Will They Run & Hide Then ???

    • kindly get a real life instead of sitting at your internet connected device all day looking for vaccine content that you can troll. And lose the caps lock. Oh, and the more exclamation points used in a row is generally a clear indicator of how irrational the author is. Just saying.

  • Why are “we” puzzled? It’s clear that the internet has allowed parents, kids, and families at large, to research their own medical decisions, further putting their choice of medical procedures into their own hands. Informed consent, in the age of the internet, is a wonderful thing. As for the HPV vaccine, who in their right mind would want their child to receive this vaccination, given it’s reception in Japan and Europe? There are some parents in Rhode Island that are reading this article and plotting a move.

    • as a survivor of a HPV cancer, and a believer in evidence from proper science, I do not comprehend why any physician would not wholeheartedly promote this vaccine. I am glad you are not my, nor any member of my family’s, physician.

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