Vaccines work. We know this through years of evidence-based research. Unfortunately, there are growing numbers of people in the United States and around the world who question the science and forgo these lifesaving preventive measures. Western North Carolina, specifically Buncombe County, has seen this trend over the last decade with high kindergarten vaccine exemption rates and outbreaks of vaccine-preventable disease affecting the community.
The percentage of kindergarteners with a religious exemption to at least one required vaccine has risen dramatically in Buncombe County over the last 20 years, from 0.62% in the 1999-2000 school year to 5.51% in the 2018-2019 school year (email communication, North Carolina Department of Public Health Immunization Branch). While it remains relatively low, the statewide percentage of kindergarten religious exemptions has increased from 0.12% in the 1999-2000 school year to 1.5% in the 2018-2019 school year [1, 2].
As would be expected, the high rates of religious exemptions to vaccines in children entering kindergarten in Buncombe County year after year have contributed to increased cases and outbreaks of vaccine-preventable diseases in schools, as well as the larger community. Pertussis and varicella (chickenpox) have been the most common. In 2014, there were 69 cases of pertussis in the county [3]. While subsequent years have seen lower case numbers, since 2017 they have been back on the rise, with 45 cases in 2019 (internal data). Just like pertussis, cases and clusters of varicella tend to arise in local schools each year. In the fall of 2018, Buncombe County faced an outbreak of varicella in a small private school where over 72% of the student population was unvaccinated against varicella. The local health director and public health staff instituted measures to help control the spread of infection, including the issuance of 104 quarantine orders for students at the school. This outbreak resulted in 41 cases of varicella, one hospitalization, and countless hours of work and school missed by community members, and required over 550 hours of county staff time (internal data), all of which was preventable by a vaccine.
The trends seen in incidence of vaccine-preventable disease coupled with the steady increase in the percentage of kindergarteners with religious exemptions to vaccinations were a call to action for Buncombe County. In partnership with the Mountain Area Health Education Center (MAHEC) and Mission Children’s Hospital, Buncombe County Health and Human Services held a health education event called “Shield of Protection - Mobilizing Efforts to Increase Immunization Uptake in Western North Carolina” in March 2018. This event provided continuing education credits for multiple disciplines and was promoted to the broader public with the goal of attracting parents and other concerned community members. During this event, we presented local data around vaccination rates and announced the formation of the Shield of Protection Immunization Coalition.
The goal of the coalition is to increase immunization rates in Western North Carolina by utilizing strategies that address all levels of the social ecological model (SEM). The SEM framework includes the following levels of influence: intrapersonal factors, interpersonal processes, institutional factors, community factors, and public policy [5]. During the March 2018 event, we broke out the over 100 attendees into small groups and started the work of the coalition. The small groups brainstormed strategies and resources needed for each level of the SEM, e.g., creating peer-to-peer outreach groups, social media presence, engaging religious leaders, publishing immunization rates at child care facilities and schools, and advocacy for law changes requiring proof of vaccine education as a requirement for vaccine exemptions.
Over the last two years, we prioritized these strategies and developed two small subcommittees. One committee works on education for individuals, interpersonal groups, and communities. The second committee is focused on policy at the organization, local, state, and national levels. The coalition has developed a private Facebook group to share evidence-based resources that members can use to facilitate conversations with others in their sphere of influence who may be vaccine hesitant. We hold quarterly meetings providing updates on pertinent vaccine topics in the region, subcommittee updates, and trainings such as social media best practices. We have over 100 members throughout Western North Carolina including medical providers, pharmacists, and nurses, but most importantly we have active community members invested in this work.
Why is this story important? Now more than ever we must raise the voice of vaccines. The facts are: most people vaccinate, and vaccines work. This should be the loudest narrative in communities across the nation. Parents, pregnant women, children, teens, and adults who choose prevention in the form of vaccines need to speak out. This is your call to action: spread the word and build a Shield of Protection around yourself, your family, and your community; be the voice for vaccines.
Acknowledgments
I would like to acknowledge Dr. Jennifer Mullendore, MD, MSPH and Dr. Susan Mims, MD, MPH for helping form the Shield of Protection Immunization Coalition and as tireless vaccine champions. I would also like to thank all the members of the Shield of Protection Immunization Coalition for their dedication to promoting and protecting the public’s health from vaccine-preventable disease.
Potential conflicts of interest. E.V. reports no relevant conflicts of interest.
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