Vaccine Hesitancy in North Carolina: The Elephant in the Room?

Lavanya Vasudevan; Emmanuel Walter; Geeta Swamy

doi:10.18043/ncm.82.2.130

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FIGURE 1.
Online Information and the Downward Spiral of Trust

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TABLE 1.

Trends in Vaccine Coverage in North Carolina, 2011-2019

	Pediatric vaccines					Adolescent vaccines				General
Year	DTaP^{^a} (24 mos)	DTaP^{^b} (K entry)	MMR^{^a} (24 mos)	MMR^{^b} (K entry)	Vaccine exemptions^{^c}	Tdap^{^d}	MenACWY^{^e}	MMR^{^f}	HPV^{^g}	Flu^{^h}
2011	94.5 (4.3)	NA	93.7 (4.7)	NA	0.2	77.8 (5.6)	65.9 (6.3)	89.4 (4.0)	54.4 (9.8)	46.5
2012	95.6 (2.8)	NA	90.2 (4.9)	NA	0.1	87.9 (4.5)	68.2 (6.4)	93.2 (3.2)	53.3 (9.7)	50.1
2013	92.1 (4.9)	NA	91.5 (4.5)	NA	0.1	89.4 (4.0)	72.4 (5.7)	87.1 (4.7)	59.3 (9.5)	51.0
2014	91.0 (5.5)	NA	89.1 (5.6)	NA	0.1	92.3 (3.7)	74.1 (5.6)	88.3 (4.3)	71.1 (8.1)	52.4
2015	95.6 (2.8)	97.1	93.7 (3.4)	97.3	0.1	93.4 (3.0)	78.5 (5.1)	91.5 (3.7)	65.7 (8.5)	50.9
2016	95.9 (2.7)	96.1	92.1 (4.1)	96.2	0.1	89.1 (4.0)	75.7 (5.6)	87.5 (4.6)	57.5 (6.4)	50.8
2017	92.1 (5.6)	96.8	92.8 (4.9)	97	0.2	91.9 (3.4)	84.8 (4.8)	93.0 (3.1)	66.8 (6.1)	46.0
2018	NA	93.2	NA	93.2	0.1	89.1 (4.1)	86.1 (4.6)	92.5 (3.5)	68.6 (6.2)	54.9
2019	NA	95.5	NA	95.5	0.1	92.0 (4.1)	93.2 (3.8)	94.3 (2.9)	71.3 (6.5)	55.8

Abbreviations. NA, Not available; DTaP, Diphtheria, Tetanus toxoid, acellular Pertussis; MMR, Measles, Mumps, Rubella; K, Kindergarten; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; MenACWY, Meningococcal conjugate; HPV, Human Papillomavirus; mos, months.
↵a Childhood vaccination coverage among children 2 years old in NC, National Immunization Survey-Child (NIS-Child), birth years 2011 through 2017. Data shown for ≥3 doses of DTaP and ≥1 dose of MMR vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/interactive-reports/trend/index.html
↵b Estimated vaccination coverage among children enrolled in kindergarten in NC, School Vaccination Assessment Program, 2009-10 through 2019-20 school years. Accessed on January 25, 2021 from https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/coverage-trend/index.html
↵c Estimated number and percentage of children enrolled in kindergarten with an exemption from one or more vaccines in NC, School Vaccination Assessment Program, 2009-10 through 2019-20 school years. Accessed on January 25, 2021 from https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/exemptions-trend/index.html
↵d Tetanus-diphtheria toxoids (Td) or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination coverage among adolescents 13-17 years in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Values shown for ≥1 dose of Tdap vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/td-tdap/index.html
↵e Meningococcal conjugate (MenACWY) vaccination coverage among adolescents 13-17 years in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Values shown for ≥1 dose of MenACWY vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/menacwy/index.html
↵f Measles, mumps, and rubella (MMR) vaccination coverage among adolescents 13-17 years in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Values shown for ≥2 doses of MMR vaccine. Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/mmr/index.html
↵g Human papillomavirus (HPV) vaccination coverage among adolescents 13-17 in NC, National Immunization Survey-Teen (NIS-Teen), 2011 through 2019. Data shown for ≥1 dose of the HPV vaccine (2011-15: females only; 2016-19: males and females). Accessed on October 30, 2020 from https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/hpv/trend/index.html
↵h Seasonal influenza vaccination coverage estimates for persons 6 months and older in NC, National Immunization Survey-Flu (NIS-Flu) and Behavioral Risk Factor Surveillance System (BRFSS), 2010-11 through 2019-20 influenza seasons. Accessed on October 30, 2020 from https://www.cdc.gov/flu/fluvaxview/reportshtml/trends/index.html

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TABLE 2.

Key Challenges and Recommendations for Mitigating Vaccine Hesitancy

Challenges	Recommendations
*Challenge 1: Lack of timely data on vaccine hesitancy*	Include measurement of vaccine hesitancy in routine population-based surveys to enable timely data on hesitancy trends and reasons. Conduct routine screening of vaccine-eligible populations for hesitancy in health care settings for proactive targeting of counseling interventions.
*Challenge 2: Inadequate access to trusted sources of information*	Incentivize providers to counsel hesitant individuals through reimbursement and use of quality metrics for value-based care. Modify medical and continuing education curricula to train providers on vaccine hesitancy and effective communication strategies.
*Challenge 3: Structural barriers to vaccination*	Outreach to homes or community-based vaccination sites such as schools, churches, and pharmacies to increase vaccine access. Strengthen public health infrastructure and linkages to local health departments/federally qualified health centers to bridge insurance and access gaps for rural populations.
*Challenge 4: Ease of seeking exemptions*	Reduce non-medical exemptions. Increase oversight of vaccine mandates for homeschooling.
*Challenge 5: Complacency toward vaccinations*	Implement standing orders for routine and recommended vaccines in health care settings. Use digital health reminder-recall interventions to support series completion and uptake of seasonal vaccines.