Flagler Health Department Wants To Offer Free HPV Vaccine to Teen Students, But School Board Is Unconvinced

The Flagler Health Department is asking the Flagler County school district to open district schools to voluntary and free vaccination for HPV, the sexually transmitted disease responsible for some 31,500 cancers a year affecting men and women.

The proposal would make Flagler the fourth county in the state to take part in a state and national goal to substantially improve HPV vaccination among teens. Health department officials submitted the proposal to the Flagler County School Board in a workshop Tuesday. There was more skepticism and resistance than outright agreement on board members’ part, with questions about the sort of information that would go to parents and further interest in a broader policy discussion about the proposed approach.

“Our interest,” Health Department Administrator Bob Snyder said, “is not to mandate anything. All we’re trying to do is educate and then give parents a choice so that if 10 parents sign the parental consent form, like they do for the flu vaccine, like they do for tdap and anything else and HPV, great, wonderful, then we’ll administer 10 vaccines. If it’s 10, wonderful. But it’s all up to the parents. No one is mandating anything. It’s to educate, inform, and with parental consent have us be available to provide the vaccination for those children of the parents who have been informed and consent to have this happen. That is our ask.”

“I’d like the board to have a conversation, as a school district because this is making policy, not just for now, but for the long term,” Board Chairman Janet McDonald said.

Its incidental association with sex aside, it wasn’t clear, however, how providing the HPV vaccine would differ from providing numerous other vaccines as a matter of policy. The HPV vaccine is not on the list of required vaccines, but nor are flu vaccines, which are provided routinely to students and staff, and in great numbers. The matter will be discussed again at a subsequent workshop.

But Tuesday’s workshop illustrated the difficulties in the health department’s way at a time when reams of misinformation, bogus facts and unfounded fears have been spreading virally about vaccines, especially on social media, convincing even prominent public figures and elected officials to pause, to be vaccine skeptics or outright deniers.

Flagler County is no exception: its youngest children have the second-lowest rate of immunization for required vaccines in the state. And some of that resistance to vaccines was evident on the school board during Tuesday’s discussion. Snyder was well aware of the difficulties he was facing. He approached the subject strategically, easing into the subject through more familiar ground.

“I think by now most of you are aware of the widespread measles outbreak in the United States,” he told members of the school board–at least those members in attendance: Janet McDonald, Maria Barbosa and Andy Dance. “These cases have been imported from international travel and local outbreaks have occurred because vaccination rates have decreased considerably around the country.”

The number of measles cases in 27 states surpassed 1,000 even though measles was eradicated, according to the Centers for Disease Control, in 2000. “This is alarming news because measles is very contagious, can cause death and is very preventable.”

Locally, Snyder said, the health department is concerned about another issue: the fact that the county has the second-highest religious-based exemption to keep children from being immunized. Parents sign that exemption, “putting their children and other Flagler County children at high risk for communicable disease,” he said. “The percentage of kindergarteners who have all their required, medically required vaccines is among the lowest in the state, at 92 percent, which is below the state target of 95 percent. In the 20th century it was considered a major scientific and public health achievement when smallpox and polio were eliminated as public health threats. Today, vaccines still matter. Our first request of the school board is to join the health department in assisting us with outreach efforts in getting the word out that vaccines are indeed safe and effective.”

He then turned the discussion over to Stephen Bickel, the department’s medical director.

“A lot of the discussion about vaccines makes no sense if you don’t understand some of the basic biology, and some of the discussions in the media are almost comical,” Bickel said, before giving a brief explanation of infections and the “war going on inside your body” to get rid of the infection, assuming it can be rid of. He also explained the body’s way of getting primed to eliminate infection before it happens–the principle behind vaccines, which are obviously not developed or maintained for every illness, whether because of cost-benefit analyses, effectiveness or because research hasn’t yet succeeded in developing a particular vaccine (HIV and malaria come to mind).

Only then Bickel turned to the central point: the human papillomavirus, or HPV, vaccine. The commonly sexually transmitted virus was long associated for cervical cancer. In more recent years it’s been associated with other forms of cancer affecting women and men, including throat and tonsil cancers. In all, 31,500 cancers a year are believed to be caused by HPV.

“Why would we want to have a vaccine for HPV?” he asked rhetorically. “Well, it is a very common infection. It’s estimated that 80-plus percent of people, sexually active adults, will have HPV sometime in their lifeti,me. Eighty percent. The reason is, it’s very contagious, and it’s very prevalent.” And it hangs out in the body for the body for ever. “So if you don’t get rid of it before it starts, you’re going to have it,” Bickel said. “That means you’re going to do this lifelong battle trying to figure out if it’s going to give you cancer or not.”

HPV is effective at a rate of 90 percent or better, for 10 years. It may require a booster after 10 years. The push has been to get the vaccine into the schools before people become sexually active. But Flagler is behind the curve. Some eight cases of cancer could be prevented a year in Flagler, perhaps three to four deaths a year.

There are practical obstacles, among them “vaccine fatigue,” Bickle said. But there’s also the sense that it’s new, the connection between the vaccine and the disease it would prevent is more distant. Then there’s the connection between the vaccine and the perception–perception is key–that because of its connection to a sexually transmitted disease, administering it would then prompt a greater level of sexual activity. Since it’s administered to younger people, some parents have been resistant, adopting the same approach sometimes associated with contraceptives: “If my child has access to contraceptives, my child will have more sex.”

The perception is not supported by fact. Research shows that. But exhaustive research also shows that vaccines don’t cause autism. That hasn’t stopped a growing minority of people from opposing vaccines because of such fears however baseless (and demonstrably dangerous, given the consequences for public health).

Bickel doesn’t deny that some vaccines have, on very rare occasions, unintended reactions. But the greater problem is with “imagined risks,” he said. “The medical community has sort of sat back for 20, 30 years, sometimes with amusement, sometimes with indignation, sometimes with shock, about some of the stories that have been put out there about vaccines, virtually none of which have panned out.” He read from a medical journal’s opinion about such fallacies, which reflect the medical community’s new posture: to fight back.

Bickel and Snyder had carefully, deliberately and craftily bracketed their approach in convincing evidence to make an essential point: the school district must be cooperative with the health department’s push for the HPV vaccine in schools. They would not have had to be so careful had they known that the full school board is entirely behind the vaccine push. But it isn’t.

Nationally and Florida, public health officials’ goal Snyder said, is that by Dec. 31, 2021, at least 50 percent for males and 70 percent of girls 13 to 17 years old have received the HPV vaccine. The estimate in Flagler is 30 percent at best, Snyder said. “So with parental concent, we would like to begin administration of the HPV vaccine and have our school system join the three school systems that are doing this in the state.” Citrus, Monroe and Santa Rosa are doing so.

“At the bottom line this is all about the public health of our children,” Snyder said–and the prevention of nine cancers, in the case of HPV.

But the presentation still elicited doubting questions from board member Maria Barbosa, who wondered what cancers could be prevented, and asked for reseach showing how the vaccine would “open gates to start having sex earlier.” But Bickel had moments earlier stressed that there was no connection–and cited again five studies that showed no connection. Barbosa was nevertheless still skeptical, seeing the vaccine as “green-lighting” sex. Bickel repeated the findings refuting the fear a third time.

“I do a lot of HIV prevention and treatment,” Bickel said of the high-risk patients he treats, by way of comparison. “What we found generally, very consistently, is that more information leads to less risky behavior–not always less behavior, sexual behavior, but less risky behavior, but often less sexual behavior rather than the opposite.”

“I don’t mean to give you a hard time. Just for myself, to be clear,” Barbosa said, “I do agree on educational program.” But, she said, would the board have to be obligated to follow the education campaign with the actual vaccination? “Myself, I need more information,” she said. She also cited a family member who was taken ill by a vaccine when she was 5 years old. “Parents need to know what they are signing, too,” Barbosa said.

Health officials stressed the department’s approach would allow the parents to make the decision, while making the vaccine available. No one would be forced. The HPV vaccine is not on the list of required vaccines–at least not yet.

“We’ll put in safeguards, guardrails, that you all suggest,” Snyder said, “to ake this offering at no cost so that we can prevent cancer in the future.”

McDonald asked about the “insert information” available for each vaccine. The department said it’s providing all the CDC information on each vaccine. “That’s not enough,” McDonald said. “If we’re going to give them promotional information, we should give them all the information.”

“That’s not promotional information, that’s fact,” Stephanie Ear, a registered nurse with the department, said, clarifying that all information available will be provided for maximum transparency, including information on side effects, though side effects with the HPV vaccine have been minimal: tdap has more side effects for example.

“The only controversy I found was a political controversy, I didn’t find any medical controversy,” Bickel said as McDonald referred to instances of “damaged children.”

“I want to make one thing clear,” Bickel said. “People should really understand this if you don’t already. It’s one thing to have an anecdotal experience. It doesn’t mean it wasn’t true. It doesn’t mean it didn’t happen. It does mean we can’t conclude scientifically cause and effect.” He referred to a child who died after getting a vaccine. It turned out she had a massive, unrelated tumor. But “scientific evidence of a true reaction, even a serious reaction from this current vaccine–I’ve never seen it. The CDC has worked on this, there’s a lot of data on this vaccine,” with shots in the millions.

Dance suggested the group return with materials that will be presented to all board members, including those missing on Tuesday, such as the consent form and the information that would be sent to parents. That’s what the board agreed to.

“Don’t be mad at me,” Barbosa told the health department officials as they prepared to leave after the discussion.

The vaccine issue wasn’t the only mater on the health department’s portion of the agenda. Snyder also wanted to highlight other substantial initiatives where the department and district schools intersect. He did so actually before the discussion on the HPV vaccine, by way of further framing the department’s work in the context of essential public health initiatives.

Regarding another vaccine, for example, last year there were 600 influenza vaccines administered to children. Every year the numbers had declined. “We decided that this is probably not a good trend,” Nursing Director Bonnie Welter said. The health department took over the administration of the vaccine from another agency.

“We have doubled it and we are now up to 1,242 students who receive the vaccine and 98 teachers and staff members,” Welter said. Letters had been sent home with all required information, and without controversies. The department also ensures that children are provided all other required vaccines. The department also conducts vision and hearing screenings in kindergarten, first, third and sixth grade.

Dental Director Lisa Izzo spoke of the dental-sealant program in the schools, started with a pilot project at Bunnell Elementary last year, with dedicated space now in two of the three schools where the program is operating. “For some of these children, this is the first time they’ve really seen a dentist–or not really a dentist, but they associate as a dentist.” The program saw 266 students in the first year, then 722 when the program expanded to Rymfire. This past year, when Wadsworth was added, the program saw over 1,200 students. Next school year Belle Terre Elementary will be added.

Sealants were placed on the teeth of 754 students this year, all of whose parents had received consent forms. The program also works as a referral system, especially for students who have not had contact with dentists.