On a busy Thursday morning at Asheville Children's Medical Center, Dr. Sam Kohn made the rounds. It was toward the end of summer break, so there were lots of back-to-school check-ups and vaccines on the schedule that day.
Many visits were easy, following the simple routine of parents bringing their tots in for their shots.
However, an increasing number of visits don't follow that routine, and more and more parents have started to ask questions. Some don't come to the doctor at all.
"I'd say the trend is almost steady, where there's a larger proportion of people than I guess I would think for lots of different reasons are either skeptical of vaccines or not interested in vaccines," said Dr. Kohn.
Under North Carolina law, no student may attend any classes in any school without a certificate of immunization. Children must be immunized against diphtheria, tetanus, whooping cough, poliomyelitis, red measles (rubeola) and rubella. However, the law allows for exemptions if a child has a medical exemption, which requires a certification from a licensed physician. It also allows for an exemption for "bona fide religious beliefs" of the child's parents or guardians. This exemption requires only a written statement of the religious beliefs.
Across the state, parents have increased the use of this religious exemption. Statewide last school year, more than 5,500 kindergartners had not obtained the required immunizations within 30 calendar days of first attendance, according to N.C. Department of Health and Human Services data. That amounted to 4.6 percent of the total kindergarten population. Of those who had not received the proper vaccinations, just 120, or about 2 percent, reported a valid medical exemption.
Even as the use of the medical exemption has decreased over the past half decade, the use of the religious exemption has increased. In the 2011-12 school year, 817 children filed for a religious exemption, about 0.7 percent of total kindergarten enrollment. By the 2017-18 school year, that increased to 1,450 kindergartners, or 1.2 percent of enrollment.
Concerns among health professionals
Dr. Anthony Moody is on the faculty in the Duke Health Department of Pediatrics and a member of the Duke Human Vaccine Institute. He said the trend "certainly is a concern," as it increases the risk that any of these highly contagious diseases could spread.
Moody said that "we are kind of a victim of our own success" because medical professionals did such a good job encouraging families to vaccinate their children through the past half century. "Now people don't think about (these diseases) as being real threats," he said.
For example, before pertussis vaccines became widely available in the 1940s, about 200,000 children in the United States contracted the disease each year, and about 9,000 died as a result of the infection, according to the Centers for Disease Control and Prevention. Furthermore, researchers at the UNC-Chapel Hill Eshelman School of Pharmacy say vaccines have saved 20 million lives and $350 billion in the world's poorest countries since 2001.
Moody said he tries to explain to parents that they are not only putting their own children at risk, but other children and adults as well. Medical professionals will refer to the term "herd immunity" to mean that unvaccinated children can still be protected from diseases if they never come in contact with another person carrying the virus. But Moody points out that all of these diseases live somewhere in the world, and as international travel grows ever easier, it becomes only more likely that a child – even in remote areas of North Carolina – could come in contact with someone carrying the virus.
Worldwide, about 20 million people contract measles every year, according to CDC, including in Europe, Asia, the Pacific Islands, and Africa. If one of these highly infectious diseases travels to North Carolina, it might not spread far if vaccination rates are high. But without that protection, it could spread quickly throughout a community, putting in danger the lives of those with medical reasons for not responding to vaccines, and others, like cancer patients receiving immune-suppressant drugs.
"It's one thing to say that you are putting your own child at risk," said Moody. "But really what you are talking about is putting everyone at risk. And that's the message that we've got to put out."
There is no accepted target for "herd immunity," and Moody said the figure would change depending on the virus. For instance, measles is one of the most highly contagious diseases in the world, so there is a high likelihood of it transferring to individuals without a vaccine. In those cases, even small numbers of unvaccinated children can pose a serious risk, said Moody.