Document text
Evidence to Recommendations Framework
Wording of the age for routine HPV vaccination
Ruth Stefanos, MD, MPH
Advisory Committee on Immunization Practices
April 15, 2025National Center for Immunization and Respiratory Diseases
1
Current recommendation
https://www.cdc.gov/acip -recs/hcp/vaccine -specific/hpv.html•HPV vaccination is routinely recommended at age 11 or 12 years
•Vaccination can be given starting at age 9 years
•Since 2006 (first ACIP recommendation), the wording of age at HPV
vaccination initiation has not substantially changed
2
1996 The adolescent platform at 11 -12 years was established as “a new strategy
to improve the delivery of vaccination services to adolescents and to
integrate recommendations for vaccination with other preventive services
provided to adolescents.”
Immunization of adolescents. MMWR Recomm Rep. 1996;45(RR -13):1 -16.
2006Adolescent platform
3Society for Adolescent Health and Medicine endorsed “three distinct
adolescent vaccination visits/platforms for adolescents (11 –12-year visit, 14 –
15-year visit, and a 17 –18-year visit) to integrate and emphasize the role of
vaccination in already recommended comprehensive health care screening
and provision visits.”
Middleman AB, Rosenthal SL, Rickert VI, et al. J Adolesc Health. 2006;38(3):321 -327.
Year of Recommendation Vaccine Recommended Age
1995 Td 11–12 yrs
2005 Tdap, 11–12 yrs
MenACWY
2006 HPV 11–12 yrs
2010 MenACWY booster 16 yrs
2015 MenB * 16–18 yrs preferredAdolescent vaccination recommendations
4 *shared clinical decision -making and individuals who are at increased risk
5Representation of HPV vaccination recommendations
on child and adolescent i mmunization schedule, 2007
https://www.cdc.gov/mmwr/PDF/wk/mm5551 -Immunization.pdf
6Vaccine Birth 1
mo2
mos4
mos6
mos9
mos12
mos15
mos18
mos19–
23
mos2–3
yrs4–6
yrs7–10 yrs 11–
12
yrs13–
15
yrs16
yrs17–
18
yrs
HPV
Range of
recommended
ages for all
childrenRange of
recommended
ages for catch-
up
immunizationRange of
recommended
ages for
certain high-
risk groupsRange of
recommended
ages for non-high-
risk groups that
may receive
vaccine, subject
to individual
clinical decision
making ttps://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/past/2017-child.pdfSee
footnote
13
hRepresentation of HPV vaccination recommendations
on child and adolescent i mmunization schedule, 2017
7 Notes and full schedule available at: https://www.cdc.gov/vaccines/hcp/imz -schedules/child -adolescent -age.htmlVaccine Birth 1
mo2
mos4
mos6
mos9
mos12
mos15
mos18
mos19–
23
mos2–3
yrs4–6
yrs7–10 yrs 11–
12
yrs13–
15
yrs16
yrs17–
18
yrs
HPVSee
notes
Range of
recommended
ages for all
childrenRange of
recommended
ages for catch-
up vaccinationRange of
recommended
ages for
certain high-
risk groupsRecommended
vaccination can
begin in this age
groupRepresentation of HPV vaccination recommendations on Table 1
of the child and adolescent i mmunization schedule, 2022 –2025
Policy question
Should the ACIP recommendations state:
HPV vaccination is routinely recommended at age 9 –12 years
instead of
HPV vaccination is routinely recommended at age 11 or 12 years;
vaccination can be given starting at age 9 years
8
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
What is the overall certainty of this evidence for the critical outcomes?
ValuesDoes the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
AcceptabilityIs the intervention acceptable to key stakeholders?
Resource UseIs the intervention a reasonable and efficient allocation of resources?
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
9
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
What is the overall certainty of this evidence for the critical outcomes?
ValuesDoes the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
AcceptabilityIs the intervention acceptable to key stakeholders?
Resource UseIs the intervention a reasonable and efficient allocation of resources?
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
10
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
What is the overall certainty of this evidence for the critical outcomes?
Acceptability/ValuesIs the intervention acceptable to key stakeholders?
Does the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
Resource UseIs the intervention a reasonable and efficient allocation of resources?
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
11
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
What is the overall certainty of this evidence for the critical outcomes?
Acceptability/ValuesIs the intervention acceptable to key stakeholders?
Does the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
Resource UseIs the intervention a reasonable and efficient allocation of resources?
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
12
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
Acceptability/ValuesIs the intervention acceptable to key stakeholders?
Does the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
Resource UseImpact on cost -effectiveness will likely be minimal.
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
13
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
Acceptability/ValuesIs the intervention acceptable to key stakeholders?
Does the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
Resource UseImpact on cost -effectiveness will likely be minimal.
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
14
Public Health Problem
Is HPV -related disease of public health importance?
15
Estimated HPV -associated and HPV -attributable cancer
cases per year, United States, 2017 –2021
Cancer siteNumber of HPV -
associated
cancersPercentage
probably caused
by any HPV typeEstimated number probably caused by
any HPV type*
Female Male Both sexes
Cervix 11,959 91% 10,800 0 10,800
Vagina 898 75% 700 0 700
Vulva 4,418 69% 3,000 0 3,000
Penis 1,381 63% 0 900 900
Anus** 7,854 91% 5,000 2,200 7,200
Oropharynx 21,474 70% 2,300 12,900 15,200
TOTAL 47,984 79% 21,800 16,000 37,800
*Estimates were rounded to the nearest 100. Estimated counts might not sum to total because of rounding.
**Includes anal and rectal squamous cell carcinomas
Sources: https://www.cdc.gov/cancer/hpv/cases.html and http://www.cdc.gov/cancer/dataviz16
0102030405060708090100
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023Percent Vaccinated
Survey Year≥1 HPV (females, 79%)
≥1 HPV (males, 75%)
HPV UTD (females, 64%)
HPV UTD (males, 59%)≥1 Tdap
≥1 MenACWYHPV vaccination
recommendation
for malesEstimated vaccination coverage, adolescents aged 13 –17 years,
National Immunization Survey -Teen, United States, 2006 –2023
UTD: up -to-date
Pingali C, Yankey D, Chen M, et al. MMWR. 2024;73(33):708 -714.HPV vaccination
recommendation
for females
17
Quadrivalent HPV vaccine -type prevalence declined 85%
among 14 –24-year -old sexually experienced females
18.5
2.8
0510152025
2003 –2006 (prevaccine era) 2007 –2010 2011 –2014 2015 –2018Quadrivalent type prevalence, %85%
Decline
Rosenblum HG, Lewis RM, Gargano JW, Querec TD, Unger ER, Markowitz LE. Ann Intern Med. 2022;175(7):918 -926. 18
Stefanos R, Lewis RM, Querec TD, Gargano JW, Unger ER, Markowitz LE. Hum Vaccin Immunother . 2024;20(1):2308378.0510152025
White, non-Hispanic Black, non-Hispanic Mexican AmericanQuadrivalent type prevalence, %2003 –2006 2015 –2018
82% 86%Quadrivalent HPV vaccine -type prevalence declined >80%
among 14 –24-year -old sexually experienced females in
different racial/ethnic groups
100%
19
Estimated number of cervical precancer (CIN2+) cases per
year, United States, 2008 and 2016
Error bars indicate range of low and high estimates based on lower -incidence and higher -incidence sites.
McClung NM, Gargano JW, Park IU, et al. MMWR. 2019;68(15):337 -343.20
CIN2+ and CIN3+ declined in young women, HPV -IMPACT,*
2008 –2022
2102004006008001000120014001600
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022Incidence per 100,000
YearCIN2+
20–24-year -olds observed 25–29-year -olds observed 20–24-year -olds modeled 25–29-year -olds modeled
*HPV -IMPACT: Human Papillomavirus Vaccine Impact Monitoring Project https://www.cdc.gov/hpv -impact/about/index.html
Gargano JW, Stefanos R, Dahl RM, et al. MMWR. 2025;74(6):96 -101.02004006008001000120014001600
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022Incidence per 100,000
YearCIN2+ per 100,000 screened women
CIN2+ includes grades 2 or worse and adenocarcinoma in situ.050100150200250300350400450
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022Incidence per 100,000
YearCIN3+ per 100,000 screened women
CIN3+ includes grade 3 and adenocarcinoma in situ.
Cervical cancer declined in young women, United States
Cancer Statistics, 1999 –2017
Age 21 -24 years
SCC: squamous cell carcinoma
Mix JM, Van Dyne EA, Saraiya M, Hallowell BD, Thomas CC. Cancer Epidemiol Biomarkers Prev. 2021;30(1):30 -37. 22
Estimated costs of HPV -attributable disease
23Clay PA, Thompson TD, Markowitz LE, Ekwueme DU, Saraiya M, Chesson HW. Vaccine. 2023;41(14):2376 -2381.•CDC estimated annual direct medical costs of HPV -attributable disease
in 2020 US dollars, published in 2023.
•Annual total cost of HPV -attributable disease is $9.01 billion.
•Annual total cost due to treatment is $4.05 billion.
•37,800 HPV -attributable cancers are diagnosed in the US annually.
•HPV vaccination coverage lags behind other adolescent vaccinations.
•HPV vaccination has led to decreases in infection prevalence and
cervical precancer incidence, and there are early signs that vaccination
has decreased cervical cancer incidence in young women.
•Total cost of HPV -related disease is $9.01 billion.Summary: Public Health Problem
24
Public Health Problem : Work Group Interpretation
Is HPV -related disease of public health importance?
No Probably No Probably Yes Yes Don’t Know Varies
25
Benefits and Harms
How substantial are the desirable anticipated effects of changing the wording of the age for routine
vaccination to 9 –12 years ?
How substantial are the undesirable anticipated effects of changing the wording of the age for routine
vaccination to 9 –12 years ?
Do the desirable effects outweigh the undesirable effects of changing the wording of the age for routine
vaccination to 9 –12 years ?
26
Potential benefits and harms
Benefits
•Clarity
•Flexibility Harms
•Separation from adolescent platform
•Prompts at age 9 may not be acceptable
to some providers
27
Benefit: Wording change would increase clarity
HPV vaccination is routinely recommended at age 9 –12 years
instead of
HPV vaccination is routinely recommended at age 11 or 12 years;
vaccination can be given starting at age 9 years
28
Benefit: Wording change may increase flexibility for
providers who would like to vaccinate at age 9
•Some partners are interested in vaccination at age 9
•9–12 wording would change Clinical Decision Support for Immunization
(CDSi ) resources and may increase flexibility for providers who are
interested in vaccination at age 9
29
CDSi implications
•If change adopted:
•Minimum age: 9 years
•Earliest recommended age: 9 years
Prompt for HPV vaccination occurs at
earliest recommended age (9 years)•Current:
•Minimum age: 9 years
•Earliest recommended age: 11 years
Prompt for HPV vaccination occurs at
earliest recommended age (11 years)
30 https://www.cdc.gov/iis/cdsi/index.html
31 Notes and full schedule available at: https://www.cdc.gov/vaccines/hcp/imz -schedules/child -adolescent -age.htmlVaccine Birth 1
mo2
mos4
mos6
mos9
mos12
mos15
mos18
mos19–
23
mos2–3
yrs4–6
yrs7–10 yrs 11–
12
yrs13–
15
yrs16
yrs17–
18
yrs
HPVSee
notes
Range of
recommended
ages for all
childrenRange of
recommended
ages for catch-
up vaccinationRange of
recommended
ages for
certain high-
risk groupsRecommended
vaccination can
begin in this age
groupRepresentation of HPV vaccination recommendations on
Table 1 of the child and adolescent i mmunization schedule
32Vaccine Birth 1
mo2
mos4
mos6
mos9
mos12
mos15
mos18
mos19–
23
mos2–3
yrs4–6
yrs7–10 yrs 11–
12
yrs13–
15
yrs16
yrs17–
18
yrs
HPV
Range of
recommended
ages for all
childrenRange of
recommended
ages for catch-
up vaccinationRange of
recommended
ages for
certain high-
risk groupsRecommended
vaccination can
begin in this age
groupSee notesPotential representation of HPV vaccination recommendations
on Table 1 of the child and adolescent i mmunization schedule
Policy question is changing the wording of recommended age
to 9–12 and not changing the recommended age to 9 –10
•Age 9 Systematic Review*:
-Higher vaccination series completion by age 13** when initiating at age 9 –10 vs.
11–12, but study limitations preclude a cause -and-effect interpretation.
-A small percentage of vaccinated adolescents had initiated at age 9 –10 in most
studies (2 –8%).
-There may be differences between families/providers vaccinating at age 9 –10 and
those vaccinating at age 11 –12.
-Due to multi -pronged interventions in QI studies, it is unclear if the component
focused on initiation at ages 9 –10 was responsible for increases in coverage.
*https://www.cdc.gov/acip/downloads/slides -2024 -10-23-24/04 -hpv-Brewer -508.pdf
**Some studies evaluated completion, but not by age 13 years 33
Harm: Wording change may affect adolescent platform
34•Adolescent platform was established in 1996
•HPV was licensed and recommended in 2006 as part of the adolescent
platform
•Adolescent platform (11 –12 years): HPV, Tdap, and MCV
Simultaneous administration of HPV vaccine with other
recommended vaccines among adolescents aged 13 –17
years who initiated HPV vaccine (N=12,995) — NIS-Teen,
United States, 2023
Vaccinations in a single visit n Weighted %* (95% CI)
Received HPV vaccine only 3,874 30.5 (29.0 -32.1)
Received HPV vaccine and one or more vaccine (s)
(Tdap, MenACWY , and/or flu vaccine)9,121 69.5 (67.9 -71.0)
Received Tdap and MenACWY and HPV vaccines 6,579 47.8 (46.0 -49.5)
NIS-Teen: National Immunization Survey -Teen
*Percentages were calculated among only those adolescents who initiated the HPV vaccine (12,995)35
•1,047 primary care professionals surveyed on perceived advantages and
disadvantages of recommending HPV vaccine at age 9:
-Most commonly perceived disadvantage of recommending vaccination at age 9
was parents’ lack of readiness (73%).
•2,527 primary care providers and clinical staff randomly assigned to
consider the perceived benefits of HPV vaccination at age 9 versus age 12:
-Providers were less likely to identify “parents ready to talk about HPV vaccine” as
a perceived benefit for vaccination at age 9 vs. age 12.Harm: Wording change may lead to system changes that are
not acceptable to some providers
36Kong WY , Huang Q, Thompson P , Grabert BK, Brewer NT, Gilkey MB. Acad Pediatr . 2022;22(4):573 -580.
Kahn BZ, Reiter PL, Kritikos KI, Gilkey MB, Queen TL, Brewer NT. Hum Vaccin Immunother . 2023;19(1):2172276.
•Changing the wording of the age for routine vaccination to 9 –12 may provide clarity
and flexibility to support those providers who are interested in vaccination at age 9.
-Vaccination at ages 9 –10 years is associated with increases in completion by age 13* but due
to limitations in studies, it is unclear if this association is causal.
-QI/Intervention studies have found increases in initiation at all ages and increased
completion but unclear contribution of vaccination at ages 9 –10 due to multiple
interventions implemented simultaneously.
•48% of adolescents receive the HPV vaccine as part of the adolescent platform and
70% receive it with one or more vaccines; changing the wording of the age for
routine vaccination may negatively affect the adolescent platform.
•Changing the wording to 9 –12 may lead to system changes or prompts to providers
for vaccination at age 9 which some may not find acceptable.Summary: Benefits and Harms
*Some studies evaluated completion, but not by age 13 years 37
Benefits and Harms : Work Group Interpretation
How substantial are the desirable anticipated effects of changing the wording of the
age for routine vaccination to 9 –12 years ?
How substantial are the undesirable anticipated effects of changing the wording of
the age for routine vaccination to 9 –12 years ?
38Don’t Know Minimal Small Moderate Large Varies
Minimal Small Moderate Large Don’t Know Varies
Benefits and Harms : Work Group Interpretation
Do the desirable effects outweigh the undesirable effects of changing the
wording of the age for routine vaccination to 9 –12 years ?
39Favors change
in wordingFavors current
wordingFavors both wording
options equallyDon’t Know Varies
Acceptability/Values
40Is changing the wording of the age for routine vaccination to 9 –12 years acceptable to key stakeholders
(e.g., providers, professional societies, or advocacy groups)?
Do parents feel that the desirable effects of changing the wording to 9 –12 are large relative to the
undesirable effects of changing the wording?
Is there important uncertainty about, or variability in, how much parents value changing the wording to
9–12?
American Academy of Pediatrics Recommendations
Beginning in the 2018 –2021 Red Book , HPV vaccination recommendation language
was modified.
“The AAP recommends starting the series between the ages of 9 and 12 years, at an
age that the pediatric health care professional deems optimal for acceptance and
completion of the vaccination series.”
American Academy of Pediatrics. Red Book: 2024 -2027 Report of the Committee on Infectious Diseases (33rd Edition) 41
HPV Vaccination Roundtable and American Cancer Society
https://hpvroundtable.org/
https://hpvroundtable.org/wp -content/uploads/2023/05/2021 -HPV -VACs -Impact -Report.pdf
Foley S, Nkonga J, Fisher -Borne M. Hum Vaccin Immunother . 2023;19(1):2167906.
•The National HPV Vaccination Roundtable is a
coalition of about 90 organizations.
•The National HPV Vaccination Roundtable has
encouraged providers to vaccinate at age 9 years.
42
Adolescent medicine stakeholder comments
Adolescent Immunizations: A Position Paper of the Society for Adolescent Medicine:
“The development of three distinct adolescent vaccination visits/platforms for adolescents (11 –12-
year visit, 14 –15-year visit, and a 17 –18-year visit) to integrate and emphasize the role of
vaccination in already recommended comprehensive health care screening and provision visits. The
11–12-year platform is the primary immunization platform promulgated by ACIP .”
Potential Changes to the Adolescent Immunization Schedule: Implications for the Stability of
Adolescent Immunization Platform Visits:
“Moving HPV vaccination to ages 9 –10years weakens the established platform…which could
unintentionally result in lower adolescent vaccination rates overall.”
Middleman AB, Rosenthal SL, Rickert VI, et al. J Adolesc Health. 2006;38(3):321 -327.
Middleman AB, Zimet GD. J Adolesc Health . 2024;75(4):538 -542. 43
2 Clinician Interviews :
-1 intervention study: providers/nurses reported a positive experience with
recommending vaccination at age 9 –10
-1 qualitative study: providers/staff had mixed opinions on initiating at age 9
3 Clinician Surveys :
-1 survey: among those not currently recommending at age 9, 61% willing to do so
-1 survey: strong provider recommendations differed by age group of patient and
specialty of provider
-1 survey: provider recommendation at age 9 depended on recommendation framingSummary: provider behavior/perspective studies (N=5)
44Biancarelli DL, Drainoni ML, Perkins RB. J Pediatr . 2020;217:92 -97.
Vielot NA, Lane RM, Loefstedt K, et al. Pilot Feasibility Stud. 2023;9(1):153.
Kong WY , Huang Q, Thompson P , Grabert BK, Brewer NT, Gilkey MB. Acad Pediatr . 2022;22(4):573 -580.
Lake P , Fuzzell L, Brownstein NC, et al. Hum Vaccin Immunother . 2023;19(1):2181610.
Kahn BZ, Reiter PL, Kritikos KI, Gilkey MB, Queen TL, Brewer NT. Hum Vaccin Immunother . 2023;19(1):2172276.
2 Caregiver Studies:
-Few caregivers reported receiving information or recommendations to vaccinate
children before age 11.
-Most reported willingness to vaccinate at ages 9 –10.Summary: caregiver behavior/perspective studies (N=2)
Aragones A, Gany F, Kaplan A, Bruno D. Hum Vaccin Immunother . 2022;18(6):2136444.
Kohler RE, Wagner RB, Careaga K, Btoush R, Greene K, Kantor L. Hum Vaccin Immunother . 2023;19(3):2270842. 45
Summary: Acceptability/Values
•AAP recommendation language uses ages 9 –12.
•Some stakeholders/advocacy groups are interested in vaccination at
age 9 and changing the wording will clarify that vaccination at age 9 is
consistent with ACIP recommendations.
•Some stakeholders have raised concerns that changing the wording will
erode the adolescent platform.
•In limited number of studies, vaccination at ages 9 –10 years was
acceptable to providers and parents.
46
Acceptability : Work Group Interpretation
Is changing the wording of the age for routine vaccination to 9 –12
years acceptable to key stakeholders (e.g., providers, professional
societies, or advocacy groups)?
47No Probably No Probably Yes Yes Don’t Know Varies
Values: Work Group Interpretation
Do parents feel that the desirable effects of changing the wording to 9 –12 are large
relative to the undesirable effects of changing the wording?
Is there important uncertainty about, or variability in, how much parents value
changing the wording to 9 –12?
48No Probably No Probably Yes Yes Don’t Know Varies
No important uncertainty or variabilityImportant uncertainty or variability
Probably important uncertainty or variability
Probably not important uncertainty or variability
No known undesirable outcomesMinority opinion
Plurality opinion
Evidence to Recommendations ( EtR) Framework
EtR Domain Question
Public Health ProblemIs the problem of public health importance?
Benefits and HarmsHow substantial are the desirable anticipated effects?
How substantial are the undesirable anticipated effects?
Do the desirable effects outweigh the undesirable effects?
Acceptability/ValuesIs the intervention acceptable to key stakeholders?
Does the target population feel that the desirable effects are large relative to
undesirable effects?
Is there important uncertainty about or variability in how much people value the
main outcomes?
Resource UseImpact on cost -effectiveness will likely be minimal.
EquityWhat would be the impact on health equity?
FeasibilityIs the intervention feasible to implement?
49
For more information, contact CDC
1-800-CDC-INFO (232 -4636)
TTY: 1 -888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
Acknowledgements
50Sarah Brewer, PhD, MPH
Carla DeSisto, PhD, MPH
Julia Gargano, PhD
Lauri Markowitz, MD