1. POST-PARTUM PERIOD: an
excellent OPPORTUNITY FOR
HPV VACCINATION
Dr. Sharda Jain
Director :-
DR. Jyoti Agarwal
Chairman PCH OBST/ Gynae Dpt.
Presented at Opinion leaders meet on HPV vaccine at Delhi 4/8/2013

2. Human
Suffering
Due To
1 out of 4
•women who die due to Cervical Cancer in
the world is an Indian
Cervical
Cancer in India
Is depressing

3. We Know The Cause !!
HPV has been detected in 99.7% of
cervical cancer worldwide the highest
level of associated identified for a
specific cause of a major human cancer.
Walboomers jM et al. j pathol, 1999: 189:129

4. Cervical
Cancer1,3
45%
12-70%
~100%
Penile
Cancer3
Vulvar
Cancer1
Head &
Neck
Cancer3
~100%
Vaginal
Cancer1
Genital
Warts1,3
Anal
Cancer1-3
~40%
60-90%
80+%
Percentages represent cases atrributable to HPV infection

5. We also Know the
STRATEGY
This cancer is 100% Preventable !!
Regular screening
vaccination
offers best possible protection
against Cervical Cancer

7. How
To
Handle
C
E
R
V
I
C
A
L
Cancer
In India

8. Vaccination
Famous Phase III trials HPV vaccines
• FUTURE – Females Unites to unilaterally
reduce Endo/ Ectocervical Disease
• PATRICIA – Papilloma Trial Against
Cancer In Young Adults

9. Universal Vaccination
GOI – has no money
for universal vaccination

10. First Fact
• Sexually active women and women
with previous abnormal cervical
cytology can receive the HPV vaccine
• Benefits may be limited to the
protection against infection of HPV
genotypes with which they have not
been infected

11. Second Fact
The efficacy of the vaccine against cervical
disease is reduced among women who
are HPV seropositive at the time of
vaccine administration

12. FOGSI Recommendations:
Vaccination & Screening
• Screening/ HPV test is not required
prior to vaccination
• Screen positive women may be
vaccinated after counseling
www.fogsi.org/hpv vaccine

13. Catch up Vaccination
Is
Thus a
Big Challenge !!

14. Herold Zur Hausen
The Nobel Prize Winner, Medicine 2008
HPV is the necessary or the key cause of cervical
cancer
Cervical cancer does not and will not develop in
the absence of the persistent
presence of HPV DNA.

15. Human Papillomavirus (HPV)
HPV is a necessary cause of cervical cancer – 99.7%4
Cancer causing Types1,2,4
HPV
Non-cancer causing types1,2
HPV 16
HPV 6
HPV 18
HPV 11
>75% of Cervical Cancer5,6
>50% of Vaginal & Vulvar Cancer5
90% of Anogenital warts5
1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J
Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J
Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical
Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6. Bhatla N et al.Vaccine (2008;26; 2811-17

16. Answer Honestly
Do we know fully about
?
• The beneficial effects of medical
intervention to recommend it ?
Or
• The harmful effects before concluding
that risk outweigh the benefits?

17. *Knee jerk reaction*
Should we err on side of caution or hope ?
Medical Knowledge is always
Incomplete and ambiguous

20. Promise of - New Life
NEW
GOI - Focus on adolescents
vaccination
- See & treat mission
Gynaecologists & Individuals
- Focus on
catch up vaccination
- screening
Postpartum HPV vaccination
D
I
R
E
C
T
I
O
N

21. POST-PARTUM PERIOD: AN
OPPORTUNITY FOR HPV
VACCINATION

22. FOGSI Recommendations:
Pregnancy and Lactation
• Cerverix - Not recommended
during pregnancy
• Gardasil - Can be given in
lactation period
www.fogsi.org/hpv vaccine

23. Postpartum HPV Vaccination
23
Two Facts
• The success of catch-up vaccination of
young women after delivery depends on
baseline prevalence of high-risk genotypes
16 and 18 in this target group. [1]
So far, HPV infection rates have been shown
to vary from 10% to 37% in pregnant women
in previous reports [1]
• Motivation & compliance looks easy
1. Rama, Villa, Pagliusi et al, Opportunity for catch-up HPV vaccination in young women after first delivery, J Epidemiol Community
Health 2010;64:610e615
2 . Wrig ht, G o v ind a p p a g a ri, Pa wa r e t a l, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bs te t
G y ne c o l 2 0 1 2 ; 1 2 0 : 7 7 1 – 8 2

24. 2 Studies
24
• RAMA AND COLLEAGUES conducted a study to determine
cervical type-specific HPV DNA prevalence and risk factors
associated with HPV infection after the delivery of the first child
among low-income young women in Brazil. [1]
• WRIGHT AND COLLEAGUES - targeted intervention of HPV
vaccination during the postpartum period
- acceptance and
- compliance of women with a program of HPV vaccination
at three time points during the postpartum period. [2]
1. Rama, Villa, Pagliusi et al, Opportunity for catch-up HPV vaccination in young women after first delivery, J
Epidemiol Community Health 2010;64:610e615
2. W
right, Govindappagari, P
awar et al, Acceptance and Compliance W Postpartum Human Papillomavirus
ith
Vaccination, Obstet Gynecol 2012;120:771–82

25. 25
OPPORTUNITY FOR CATCHUP HPV VACCINATION IN
YOUNG WOMEN AFTER
FIRST DELIVERY
Primiparous 15 – 24 years
Rama et al (2006-07 ) Brazil

26. Results
26
Overall, HPV
DNA was
detected in
58.5% of the
women included
in the analysis
Rama, Villa, Pagliusi et al, Opportunity for catch-up HPV vaccination in young
women after first delivery, J Epidemiol Community Health 2010;64:610e615

27. Rama et al (2006-07 ) Brazil
27
• The HPV prevalence (58.5%) found in the young primiparous
women
• 17.3% And 13.3% - were positive, respectively, for the two
ONCOGENIC HPV TYPES, HPV 16 AND 18, ….
suggesting that the majority of this group could still draw full
benefit from catch-up HPV vaccination and protection against
cervical cancer.
• Additionally, NO WOMAN WAS POSITIVE FOR ALL THE
FOUR TYPES present in quadrivalent vaccine.
Rama, Villa, Pagliusi et al, Opportunity for catch-up HPV vaccination in young women after first
delivery, J Epidemiol Community Health 2010;64:610e615

28. Rama et al (2006-07 ) Brazil
28
This study supports that young
population would derive benefit from
catch-up vaccination in postpartum
period and represents a target
population for effective primary and
secondary cervical cancer prevention
programmes
Rama, Villa, Pagliusi et al, Opportunity for catch-up HPV vaccination in young women after first delivery, J
Epidemiol Community Health 2010;64:610e615

29. ACCEPTANCE AND
COMPLIANCE WITH
POSTPARTUM HUMAN
PAPILLOMAVIRUS
VACCINATION
29
Postpartum women 18 – 26 years (N150)
3 visits at delivery 1st dose
6 weeks second dose
6 month 3 dose
Quadrivalent HPV Vaccine
Wright et al (2012)
Obstet Gynecol 2012;120:771–82

30. Materials & Methods
30
• PRIMARY OBJECTIVE : TO ESTIMATE COMPLIANCE in
receiving three doses of vaccine when the vaccine was
administered in the postpartum setting.
• SECONDARY OBJECTIVES: TO EXAMINE THE
INFLUENCE OF KNOWLEDGE and decisional conflict on
compliance with the vaccine series and to estimate patient
SATISFACTION with postpartum vaccination.
Wright et al (2012)
Obstet Gynecol 2012;120:771–82

31. Results
31
• A total of 150 women were enrolled in the study.
• Survey results:
– 80.0% of women had heard of HPV,
– 90.7% believed that it was important to vaccinate to
prevent HPV
– 97.3%, were satisfied with the choice to undergo HPV
vaccination in the postpartum period.
Wright et al (2012)
Obstet Gynecol 2012;120:771–82
Wrig ht, G o vind a p p a g a ri, Pa wa r e t a l, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bs te t G y ne c o l 2 0 1 2 ; 1 2 0 : 7 7 1 – 8 2

32. Results
32
• After the first dose of vaccine,
– 97.2% of women felt it was worthwhile to receive the vaccine,
– whereas 98.6% said that administration was convenient.
• When asked, 50.4% of participants said they would not
have asked to be vaccinated if they were not part of the
study.
• Among those vaccinated,
– 99.3% were happy they participated in the study and
– 97.9% would have recommended the vaccine to a friend
• Despite the acceptability of this strategy, only 30.7% of
enrolled patients completed the three-vaccine series
Wright et al (2012)
Obstet Gynecol 2012;120:771–82
Wrig ht, G o vind a p p a g a ri, Pa wa r e t a l, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bs te t G y ne c o l 2 0 1 2 ; 1 2 0 : 7 7 1 – 8 2

33. Experience
Of last two years (2011-13)
(N – over 200)
POST-PARTUM PERIOD : is
excellent OPPORTUNITY FOR
HPV VACCINATION

34. 99% compliance
• Happy
• Convenient
• Recommended to her friends / Relative

35. FOGSI Recommendations:
Need for boosters & Therapeutic role
• No therapeutic role in
treating pre existing HPV
infection or CIN lesion
• No booster required - as of
now
www.fogsi.org/hpv vaccine

36. Be true to your highest conviction !!

37. Thank You