As of May 2, five cases of measles have been confirmed in eastern Tennessee, a spokesperson for Tennessee Department of Health told the Citizen Times.

With measles in our backyard, how vulnerable are Asheville-area residents to infection?

In short: No one knows. Not even the health department.

What are measles vaccination rates in Asheville?

An unspecific and rarely enforced reporting system on school vaccination rates means local health officials can't assess the level of risk until an infectious outbreak has already begun.

While many parents might assume the government tracks the vaccination of each individual child, health officials rely on reports from schools. But those reports are short on information, when they’re turned in at all.

Under North Carolina law, there are two vaccine “checkpoints” in a child’s school career— one in kindergarten and one in seventh grade, according to NC Department of Health and Human Services' website. At each of those checkpoints, the school collects proof of immunization or proof of exemption from each student and submits it to the NC Department of Health and Human Service.

Measles in Buncombe County

Buncombe County health officials receive only three numbers from these school checkpoints — a yearly tally of how many students are fully vaccinated, how many students received religious exemptions and how many students received medical exemptions.

An exemption means a child is unvaccinated “in part or in full.” That lumps together a kindergartner who missed a chicken pox booster due to a possible allergic reaction and a kindergartner who has received none of the dozens of required vaccines into the same category. And it's almost impossible to gauge the risk of an epidemic without an accurate read on what proportion of the population isn't immune.

More specific data are available only to public health officials after an outbreak has already begun.

"Having that data would really help us," Jennifer Mullendore, medical director for Buncombe County Health and Human Services told the Citizen Times in February. "Maybe a child is vaccinated against measles and not chickenpox. Having the data would really guide us."

Some schools haven’t reported vaccination rates for 2018-19

As of May 2, with the last day of class only weeks away for most, some Buncombe County schools still haven't turned in their mandatory vaccination reports for the 2018-2019 school year, according to NC Department of Health and Human Services spokesman Jim Jones.

North Carolina law requires schools to provide these tallies of vaccinated and unvaccinated students to state officials within 60 days of the start of the school year. But due to September's Hurricane Florence, Gov. Roy Cooper gave schools a 41-day extension to report data for the 2018-19 school year — bad timing for a weather emergency during the worst measles outbreak in decades.

Notably, the list of schools that has failed to report vaccination rates to the state includes the Asheville Waldorf School, Jones confirmed in an email to the Citizen Times. The school made headlines last fall, when it played host to NC's worst chickenpox outbreak in decades — nearly 75% of its 152 students were unvaccinated for the virus, and unvaccinated students were quarantined for three weeks.

Asheville Waldorf's chickenpox outbreak

NCDHHS and Buncombe County officials were unable to immediately identify how many local schools have not complied with mandatory reporting laws.

Preliminary data released to Buncombe County DHHS by state health officials indicate that, as of March, records had not been reported from five Buncombe County public schools with kindergartens (Glen Arden, Leicester, Pisgah, West Buncombe and Estes) and one Asheville City public kindergarten (Asheville Primary School).

All seven Buncombe County public schools and two Asheville City public schools with seventh-graders were accounted for.

It is unknown if any of those schools has reported vaccination records since March.

“If schools fail to report this data by the deadline, we are not able to have an accurate understanding of the potential risks that vaccine-preventable diseases pose to our schools and the larger community," Mullendore said on May 3.

She added that the data the county receive from the NC Immunization Branch doesn't specify which shots children don't have, "and therefore, which vaccine-preventable diseases they are most susceptible to contracting. Without accurate and comprehensive data, it is difficult for us to know what our shield of protection truly is at the local level. Regardless, based on the data that we do have at this time and our general knowledge about our community, we are greatly concerned about the potential for a measles outbreak in Buncombe County.”

Data for private and charter schools in the Asheville area was not immediately available.

In recent years, Buncombe County has had the highest rate of vaccine exemptions in the state, with 5.7% of kindergartners receiving religious or medical exemptions in the 2017-18 school year — that’s over four times the North Carolina average of 1.2%.

Counties along the Tennessee border have significantly lower exemption rates (2.1% in Madison, 2.1% in Haywood, 0.4% in Swain, 0.6% in Graham, and 2.9% in Cherokee), which bodes better for containment of any measles cases in the area.

Measles in national news

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A surge in cases:Number of measles cases in the U.S. reach 704, the highest point this century

UCLA, CAl State Los Angeles quarantined:Los Angeles measles quarantines impact hundreds of university students, staff

"Parents have chosen not to vaccinate their children":Anti-vaxxers open door for measles, mumps, other old-time diseases back from near extinction