Analysis of more than 16,000 US adolescents found substantial differences in human papillomavirus vaccine uptake across and within census regions, with several states showing significantly lower uptake compared with the reference state.
Human papillomavirus (HPV) vaccine uptake varied considerably by state among US adolescents, according to a retrospective, secondary, cross-sectional analysis of 2023 National Immunization Survey–Teen (NIS-Teen) data published in JAMA Pediatrics. The findings come as national HPV vaccination coverage remains below the Healthy People 2030 target of 80%.
Researchers analyzed survey-weighted data from 16,057 adolescents aged 13 to 17 years. HPV vaccine uptake was defined as receipt of at least 1 vaccine dose, meaning the study evaluated vaccine initiation rather than series completion. HPV vaccination may begin at age 9, and current recommendations call for a 2-dose series among adolescents who initiate vaccination before age 15 and a 3-dose series for those who begin later. The analysis was limited to adolescents with clinician-verified vaccination records to reduce recall bias.
Using logistic regression models adjusted for age, sex, race and ethnicity reported by a parent or guardian, insurance status, and household poverty level, the researchers compared state-level odds of HPV vaccine uptake. Alabama served as the reference state because of the coding of the state variable.
Several Northeastern states demonstrated higher adjusted odds of HPV vaccine uptake compared with Alabama. Adolescents in Rhode Island had approximately 3 times the odds of HPV vaccine uptake, while adolescents in Massachusetts had about twice the odds. Adolescents in New Hampshire demonstrated modestly higher adjusted odds of HPV vaccine uptake.
By contrast, several states—predominantly in the South—had statistically significantly lower adjusted odds of HPV vaccine uptake compared with Alabama. These included Mississippi, Georgia, Oklahoma, Kentucky, and West Virginia. New Jersey and Nevada also demonstrated lower adjusted odds despite being located outside the Southern census region.
State-level prevalence estimates showed similar patterns. Rhode Island had the lowest proportion of unvaccinated adolescents, at 8%, whereas Mississippi had the highest, at 39%. Oklahoma and Georgia also had high proportions of unvaccinated adolescents, at 36% and 35%, respectively. New Jersey, despite being located in the Northeast, had a similarly elevated proportion of unvaccinated adolescents at 34%.
The researchers noted substantial heterogeneity within census regions, building on prior regional analyses suggesting lower HPV vaccine uptake in the South compared with the West. The current study suggests that regional analyses alone may obscure important state-level differences relevant to targeted vaccination efforts.
For example, Massachusetts and Rhode Island demonstrated higher adjusted odds of HPV vaccine uptake within the Northeast, whereas New Jersey showed significantly lower adjusted odds than Alabama despite being located in the same region. In the West, Nevada had lower adjusted odds of uptake, while most other Western states did not differ significantly from the reference state.
The researchers cautioned that some state-level estimates had relatively wide confidence intervals, reflecting the limitations of smaller state-specific sample sizes. They also emphasized that the cross-sectional design precludes conclusions about causality and that the analysis did not evaluate potential drivers of state-level variation such as vaccine policy, access to care, provider recommendation practices, or parental attitudes toward vaccination.
“Importantly, some states within traditionally high-performing regions underperformed, while others within lower-performing regions exceeded expectations, underscoring the limitations of regional analyses alone,” wrote lead study author Chinenye Lynette Ejezie, PhD, MPH, of Towson University, and colleagues.
The researchers reported no conflicts of interest.
Source: JAMA Pediatrics
