This story was originally published by North Carolina Health News, story by Jennifer Fernandez

A series of child cartoon characters dressed in superhero outfits introduce topics such as the importance of child vaccinations in a series of health department videos.

The videos feature Jennifer Mullendore, medical director for Buncombe County, where a large number of children are not fully immunized. The county has seen outbreaks in recent years of preventable diseases such as chickenpox.

“These vaccine preventable diseases still exist in our community,” Mullendore said in one of the county health department’s videos that encourage residents to get their children vaccinated as part of the “A Shield of Protection for Your Child’s Health” campaign.

“If enough people are unvaccinated, it allows holes in that shield,” Mullendore said in that video. “Diseases can get in and then cause devastation in those people who don’t have the vaccine.”

Logo on a blue background featuring child cartoon characters as superheroes promoting vaccination.
Buncombe County’s health department came up with an immunization campaign several years ago to tackle the high rate of unvaccinated children. Staff came up with a logo featuring children as superheroes and the phrase “A Shield of Protection.”

Although the videos were part of a vaccination campaign from several years ago, the message is still relevant.

“We have so much research that vaccines prevent diseases, and we all want kids to be healthy and thrive,” said Elizabeth Hudgins, executive director of the North Carolina Pediatric Society

As children head back to classrooms for the 2023-24 academic year, pediatricians, schools and health departments are working to get kids up to date on required vaccinations. Most public schools resume classes this week.

While North Carolina’s child vaccination rates are better than the national average, it’s important to keep inoculation rates above 95 percent, according to Brian Bowman, a pediatrician with Apex Pediatrics in Apex.

That 95 percent mark is the threshold that experts say is needed to keep infectious diseases at bay.

“When we drop below 95 percent in a community, then that can be a problem,” he said.

North Carolina requires all children — with some exceptions — to be vaccinated before attending child care or school, whether public or private. If students don’t have the required vaccinations, they won’t be allowed at school. 

Last year, nearly 12 percent of high school students had not been fully vaccinated within the first month of school, state data show.

Not common, but not gone

In the early to mid-20th century, childhood illnesses such as polio and the measles were common, but vaccines have all but eradicated these infectious diseases.

Zack Moore, state epidemiologist and the epidemiology section chief in the Division of Public Health of the N.C. Department of Health and Human Services, called childhood vaccinations “one of the biggest advances we’ve had in public health.”

A man with dark hair wearing a blue, button-down, long sleeve shirt.
Zack Moore

Yet cases and outbreaks still happen. Last year, New York state officials identified a case of polio in an unvaccinated young adult who became paralyzed. It was the first case in the country in a decade.

In 2019, the CDC confirmed 1,274 individual cases of the highly contagious measles in 31 states. It marked the greatest number of measles cases reported in the U.S. since 1992. The majority of cases were among unvaccinated people. 

“When you have pockets of people who are not protected, it can spread really quickly,” Moore said. 

North Carolina is not immune to outbreaks of diseases that can be prevented through vaccination. Since October 2018, there have been more than two dozen of them, officials with NCDHHS told NC Health News.

Of those outbreaks, 21 involved illnesses that children must be vaccinated against before going to child care or school.

Whooping cough accounted for 16 of the outbreaks. Also known as pertussis, whooping cough is caused by a bacterial infection that can be life-threatening, especially for infants. The name “whooping cough” comes from the “whooping” sound made when those infected infants, with tiny airways, gasp for air after a fit of coughing. In a 2012 outbreak in Winston-Salem, a 2-month-old died. 

Because pertussis is caused by a bacterial infection, the protection given by a vaccine wanes over time, so it’s important for elementary school-aged children to get a booster, especially if they live in a family with infants. 

There were three outbreaks of varicella, more commonly known as chickenpox, and two of mumps

Chickenpox is a highly contagious disease caused by a virus. It causes an itchy, blister-like rash and can be life-threatening in babies and adolescents. Mumps, another very contagious disease caused by a virus, is marked by swelling of the salivary glands. It can lead to inflammation, including of the brain and the tissue surrounding the brain and spinal cord. For older males who contract the disease, mumps can cause permanent problems with sperm formation, leading to infertility.

One of the chickenpox outbreaks in 2018 affected a private school in Buncombe County where most of the children were unvaccinated, said Ellis Matheson, director of Buncombe County Public Health.

Such outbreaks affect more than student health, she said. 

“If you can’t show immunity to the disease, you can be excluded from school until the outbreak is over, which sometimes can be for weeks,” Matheson said.

A quarantine can lead to economic and education repercussions, as well, she said, as parents have to take time off work to be with their children, who lose important time being in school.

Moore said whooping cough and chickenpox outbreaks typically occur in child care settings and schools, especially those with high rates of exemption, when a person cites a medical or religious reason to not get vaccinated. Mumps outbreaks tend to be on college campuses, usually among students who’ve been vaccinated, Moore said.

No vaccine guarantees 100 percent protection against an illness. However, those who are vaccinated and become ill have milder symptoms, according to the Centers for Disease Control and Prevention


A smaller percentage of North Carolina children are being exempted from getting vaccinated for non-medical reasons compared to children nationwide, data show. But that number is growing at a faster rate in North Carolina than the nation.

In North Carolina, non-medical exemptions rose from 0.7 percent to 1.8 percent over a decade through the 2021-22 school year, the most recent CDC data show.

Over that same time period, non-medical exemptions nationwide rose from 1.4 percent to 2.3 percent.

“We have seen a little uptick in exemptions for the required vaccines,” Moore said. “But it’s still relatively low, just over 2 percent for kindergarten across the state. It’s particularly gone up in kids enrolled in private schools.”

Still, that uptick across the nation is a concern “and speaks for a need for continuing education,” he said.

North Carolina fares better than the nation as a whole for the percentage of children receiving various vaccinations.

For example, 95.9 percent of N.C. children have been inoculated against chickenpox, according to CDC data for the 2021-22 school year. By comparison, 92.1 percent of children nationwide have gotten the vaccine. 

“The bigger issue is people who do want the vaccines but have an issue with access,” Moore said, referring to such common issues as transportation, insurance and even provider availability that can prevent people from getting needed care.

Distrust, misinformation

Moore said medical professionals are still seeing a lot of misinformation and disinformation on the COVID-19 vaccines, and by extension, other vaccines.

An October 2022 article, later published in The Lancet, looked at how to keep that fear over the COVID-19 vaccine from bubbling over into routine childhood vaccinations.

“It is important that we act now to ensure childhood vaccination –– a cornerstone of public health –– remains trusted, valued, and equitably accessed,” the authors wrote.

Bowman said he is having more discussions with patients about vaccine safety than he was before. Being compassionate about their concerns is important, he said; otherwise, they won’t trust the answers given to them.

Listening is key, as is persistence in bringing up the topic at each visit to encourage parents to continue the discussion, Matheson said. 

“Because it could be that 10th visit where someone is ready to have a deeper conversation and receive more information and, ultimately, hopefully, get vaccines for themselves or their children,” she said.

So far, there has been no detectable change in vaccine rates tied to COVID-19 concerns in the state, Moore said.

“Overall, parents and pediatricians are still doing a really good job of vaccinating their kids against other vaccine preventable diseases,” he said.

Vaccination policy

In North Carolina, vaccination records are checked when a child is enrolled in a child care facility or school. Children are not allowed to attend school (whether public, private or religious) or a child care facility unless they have received all required immunizations appropriate for their age or been exempted.

Families have 30 days from the first day a student attends school to provide proof the child has received all required immunizations for that age. After that, the student can’t attend school until the family provides documentation of vaccinations or an exemption. 

The state allows for two types of exemption — medical and religious belief. 

The medical exemption requires a licensed physician to fill out a form explaining why the child can’t be vaccinated. An allergy to a vaccine component, for example, can qualify a child for a medical exemption.

For a religious exemption, the child’s parent or guardian just needs to write a statement explaining their “bona fide religious beliefs and opposition to the immunization requirements,” according to state law. The statement must include the child’s name and date of birth. It does not need to be notarized or approved by any state agency.

Non-religious personal beliefs, however, are not accepted as a reason for exemption, according to state law.

Need to get vaccinated? Find a vaccination site at

Views on required vaccinations may be changing.

Fewer parents say healthy children should get the combo MMR vaccine (mumps, measles, rubella) before attending school, according to the KFF Vaccine Monitor.

The number dropped to 71 percent in December, compared with 82 percent who said the same in an October 2019 Pew Research Center poll

The number who say parents should be able to decide not to vaccinate their school-age children, even if it creates health risks for others, has increased from 16 percent to 28 percent. 

Vaccination requirements

North Carolina law requires that children get certain vaccinations unless an exemption is requested. Here’s a look at required vaccinations and when they must be taken by:

To enter child care

  • Diphtheria, tetanus and pertussis or DTaP (five doses) – Three doses by 7 months old, booster by 19 months old, second booster on or after fourth birthday and before entering school for the first time.
  • Hepatitis B (three doses) – One dose by 3 months old, second dose by 5 months old, final dose by 19 months old.
  • Haemophilus influenzae type b, also called Hib, which protects against the most common form of childhood meningitis. (Three or four doses) – Number of doses depends on the brand of vaccine. Should be received by 16 months old.
  • Measles, part of the combined MMR vaccine (two doses) – Doses should be given at least 28 days apart. One dose between 12-16 months old, second dose before entering school for the first time. 
  • Mumps, also part of MMR combo (two doses) – One dose between 12-16 months old, second dose before entering school for the first time. 
  • Rubella, final part of MMR combo (one dose) – One dose between 12-16 months old.
  • Polio (four doses) – Two doses by 5 months old, a third dose by 19 months old, booster on or after age 4 and before entering school for the first time.
  • Pneumococcal, also called PCV (four doses) – Three doses by 7 months old, booster between 12-15 months old.
  • Varicella (chickenpox), also called Var (two doses) – Doses administered at least 28 days apart with first between 12-19 months old and second before entering school for the first time.

To enter kindergarten

Must have received the vaccinations required to attend child care. No additional vaccinations required.

To enter seventh grade

Must have received the vaccinations required to attend child care/kindergarten, plus:

  • Tetanus/diphtheria/pertussis, also called Tdap (one dose).
  • Meningococcal (one dose).

To enter 12th grade

Must have received the vaccinations required to attend child care/kindergarten/seventh grade, plus:¨C71C¨C72C¨C73C

Reporting complication

Meanwhile, health officials have less money to combat the drop in vaccinations.

The CDC has slashed vaccination program funding by what amounts to about 10 percent, officials told KFF Health News in early July.

CDC officials said in an email obtained by the nonprofit newsroom that the cut may result in less complete reporting on vaccinations.

However, Matheson said that the cut in federal funding won’t impact the Vaccines for Children Program, which provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay.

“People who are not insured, who need the vaccines for their children, absolutely can come into our clinic and receive those vaccines,” she said. “There’s also many other programs out there that help with vaccines.”

The CDC officials said the loss in funding is connected to the debt limit deal struck between the Biden administration and Congress in June. 

It’s not the first health care issue affected by the budget deal. Lawmakers also clawed back $400 million of COVID-19 pandemic aid that had been used by the CDC to hire 3,000 disease intervention specialists — public health workers who do contact tracing, investigate disease outbreaks and connect people to testing and treatment services, including for sexually transmitted infections.

“It’s not the time to be going backwards on this,” Hudgins said about routine childhood vaccination funding.

Along with the slate of vaccinations required by state law, health officials recommend children be vaccinated for a few more illnesses before school starts.

Some of the recommended vaccines would stop the spread of a trifecta of respiratory illnesses that last fall hobbled some North Carolina hospitals that didn’t have enough beds for children affected. They had to divert child patients to other facilities because so many came in with either the flu, COVID-19 or respiratory syncytial virus, also known as RSV.

Child cartoon character superheroes on cards signed by children who were immunized.
Buncombe County created a campaign to encourage childhood vaccinations. “A Shield of Protection for Your Child’s Health” features children as cartoon superheroes.

RSV usually causes mild, cold-like symptoms. However, it can be more severe for older adults and for infants — and lead to hospitalization. 

Health officials such as Buncombe County’s Matheson are encouraging families this year to get the flu and COVID-19 vaccines, as well as RSV for those most vulnerable.

Buncombe County has a mobile clinic that can help with those vaccines, and it is adding more staff and extending hours at its main clinic to help children get their required vaccinations for school.

“We’re really just encouraging everyone to assess their own vaccine status and everybody to get caught up,” Matheson said, “to create that shield of protection on themselves and their family and community.”

The CDC recommends the HPV vaccine be taken typically between age 11-12, or at least by age 26. The Food and Drug Administration approved an HPV vaccine in 2014.  

It protects against infections from the human papillomavirus that can later cause certain types of cancer, such as cervical, penile or anal cancer. Since the initiation of HPV vaccine, the incidence of cervical cancer has decreased more rapidly, leading researchers to believe this is because of the vaccine being widely available. 

HPV is the most common sexually transmitted infection, according to the CDC, with infections so common that most people will have at least one in their lifetime.

However, coverage rates in North Carolina are not as good as officials would like them to be, Moore said.

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

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