A needle is filled with vaccine ahead of a shot. Courtesy of NIH

In the middle of Western North Carolina sits one of the state’s most potentially dangerous time bombs. And, at any given moment, under the right circumstances, it could go off.

Despite North Carolina’s requirements that school-age children have up-to-date vaccinations before starting kindergarten, 5 percent of Buncombe County’s kindergarten population remained unvaccinated for the 2014-15 school year. Statistics for the 2015-16 school year are not yet available.

According to Dr. Jennifer Mullendore, medical director for Buncombe County Health & Human Services, the percentage is higher than previous years and is six times the state average.

With up to 20 percent of each of the county’s schools allowed to be unvaccinated, the possibility exists for a significant public-health crisis, she said.

“We’re holding our breath, waiting for an outbreak,” she said.

“We’re fortunate the measles outbreak in California (in April) didn’t make it here. Next time, we might not be that lucky.”


In North Carolina, a child can remain unvaccinated for two reasons: a medical exemption and a religious opt-out. Based on N.C. Department of Health & Human Services statistics, out of

Buncombe’s 2,488 kindergarteners, one has a medical exemption, including a waiver from a healthcare provider, and 125 opted out for religious reasons. Or at least that’s officially what they claim. The state does not offer a philosophical exemption, even though that’s exactly what some anti-vaccination groups in Buncombe Cuonty have advocated. It’s likely that not all “religious” waivers are faith-based.

Upon kindergarten enrollment, parents must present schools with their child’s official immunization record. Schools keep these records on file, including any medical or religious exemptions. Children without exemptions have 30 days to provide proof of immunization or they aren’t allowed to return to school.

In addition to Buncombe County, Polk County and Transylvania County round out top three WNC locales with the highest non-vaccinated rates, reporting 4.71 percent and 2.89 percent non-vaccinations, respectively.

Henderson County has the second highest total number of children without vaccinations — with one medical waiver and 14 religious exemptions. However, because this is a relatively large county for WNC, it’s rate is not especially out of the range seen in most counties across the state.

Elevated sickness

Although no widespread outbreaks have occurred, Buncombe frequently experiences a higher-than-average incidence of pertussis, also known as whooping cough, a highly contagious respiratory disease known for uncontrollable, violent coughing that makes it hard to breathe.

Despite being preventable with a vaccine, in 2014, Mullendore said, the county had 65 reported cases. Only Duplin County, a rural county near the coast known for its pig farms, had more with 138 cases.

There were 782 cases of whooping cough reported statewide in 2014.

But, knowing the reasons behind the high non-vaccination rate is difficult, Mullendore said.

“We suspect immunizations have done a great job keeping people healthy for 50-plus years, and people don’t have context for why immunizations are important,” Mullendore said.

“People who grew up in the 1960s had friends and family who died from diseases that we have vaccines for now. Younger people raising kids now never saw that, so we’ve lost that perspective.”

Immunizations for North Carolina’s children are free through the Vaccines for Children program, even for uninsured individuals. It’s possible, though, other factors that typically limit access to healthcare are also at play, including cultural or language barriers that make it difficult to take advantage of healthcare services, and, in this case, a low level of education about vaccines.

Tara Rybka, public health educator with the Transylvania County Public Health Department, said that although it’s never been directly connected to a lack of immunization, transportation difficulties frequently play a role in limiting access to healthcare services in counties like hers.

Herd sensitivity

In many cases, Mullendore said, parents research vaccines on their own, trusting potentially non-vetted, online sources rather than asking their pediatrician or other healthcare provider for information about possible risks and benefits associated with vaccinating their children. Some choose not to vaccinate based on their online findings, leaving the overall community more vulnerable to preventable disease.

Doing so is particularly dangerous, said Noel Brewer, associate professor of health behavior at the University of North Carolina at Chapel Hill Gillings School of Global Public Health.

Vaccines provide herd immunity, he said, protecting the vaccinated and sheltering those who can’t receive vaccines due to conditions that compromise their immune systems, such as cancer.

On the flip side, however, non-vaccination can also create herd sensitivity, a phenomenon that gives rise to more severe cases of disease as individuals get sick at older ages.

Since most people are vaccinated, the risk of herd sensitivity might not seem too bad. But Brewer said this perception is misleading.

“Herd sensitivity is worse than people think,” he said. “Birds of a feather flock together, so those who are unvaccinated tend to stay together. But, you never have a pocket where 95 percent of people are vaccinated. It’s usually spread out to 80 percent or it can fall to 50 percent. These are the places that are vulnerable to outbreak and the spread of disease.”

Vaccination foes

Even with the risks of non-vaccination publicized throughout the healthcare community, Buncombe County has a relatively active anti-vaccine cohort, including Moms Against Mercury.

Based in Leicester, this organization, which did not return calls for comment, publicizes and supports the belief that mercury present in vaccines adversely affects the nervous system.

In recent years, the group has held six rallies, lobbying against the use of vaccines in their current forms.

According to the Centers for Disease Control & Prevention (CDC), though, the type of mercury used in vaccines – ethylmercury – is metabolized and cleared from the body far faster than the type of mercury – methylmercury – present in some types of fish. Consequently, CDC data states, ethylmercury is far less likely to be harmful.

Educating the public

County health officials are working to combat anti-vaccine efforts, Mullendore said. Last year, the Department of Health & Human Services worked with healthcare and childcare providers to expand educational services around the facts and benefits of vaccinating children.

Rather than targeting staunch anti-vaccine proponents who tend to dig their heels in when faced with information that contradicts their beliefs, health officials are reaching out through public forums to parents who are curious about vaccines. The effort could ultimately influence those who are on the fence about whether to vaccinate to proceed with immunizations.

Jennifer Garrett, director of nursing with Macon County Public Health also suggested holding school-based vaccination clinics to reach students who aren’t yet vaccinated. Macon’s health officials also reach out via phone to non-compliant parents to set up appointments for children to be vaccinated.

Ultimately, though, UNC’s Brewer said, the onus is on parents in communities with unvaccinated children to take steps that will side-step exposure to preventable disease. When children are sick, keep them home from school, he said, and know which pediatricians still choose to treat children who don’t have current vaccinations.

And, Brewer added, public health officials should continue to push for more widespread vaccinations.

“Getting information into the hands of those who are vaccinated can be helpful,” he said.

“More information needs to come from educators and physicians in the community. Not everyone will want to vaccinate, but more people are open to it than we currently believe.”

WNC statistics by county

The following statistics for percentages of kindergarten-age children who have non-medical vaccination exemptions are for the 2014-15 school year, the most recent information available:

  • Avery 0.64%
  • Buncombe 5.02%
  • Cherokee 0.83%
  • Clay 0.91%
  • Graham 0%
  • Haywood 1.42%
  • Henderson 1.4%
  • Jackson 1.25%
  • Macon 1.9%
  • Madison 1.16%
  • McDowell 0%
  • Mitchell 1.81%
  • Polk 4.71%
  • Rutherford 0.53%
  • Swain 0.82%
  • Transylvania 2.89%
  • Watauga 1.1%
  • Yancey 0.57%

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Whitney L.J. Howell is a contributing reporter to Carolina Public Press. Contact her at whitneyljhowell@gmail.com.

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