1) A study in Brazil found that HPV prevalence in young primiparous women was 58.5%, with 17.3% and 13.3% positive for the two high-risk HPV types 16 and 18. This suggests that postpartum vaccination could provide protection against cervical cancer for most women. 2) A US study found high acceptance of postpartum HPV vaccination, with 97% of women satisfied with the choice and 98% finding it convenient. However, only 30.7% completed the full three-dose vaccination series. 3) The presenter's experience vaccinating over 200 women in India postpartum found 99% compliance, with women reporting it was convenient and recommending it to friends

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

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

3. Every 7minutes,
1 India woman dies of Cervical Cancer
Disease Burden
Capital for Cervical Cancer

4. Walboomers jM et al. j pathol, 1999: 189:12-
9
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.
We Know The Cause !!

5. 80+%
~40%
~100%
60-90%
~100%
Percentages represent cases atrributable to HPV infection
Cervical
Cancer1,3
Vulvar
Cancer1
Vaginal
Cancer1
Anal
Cancer1-3
Genital
Warts1,3
12-70%
Head &
Neck
Cancer3
45%
Penile
Cancer3

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

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

9. Why ca cervix not given importance
Govt. in India?

10. Screening – not even tip of iceberg

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

12. Universal Vaccination
Substantial effect in reducing the
morbidity of cervical cancer in
developing countries, where an
organization screening program
may not exist for all women in
near future.
Villa LL. Vaccine. 2006; 24 (suppl 1) : S2# - 8
GOI – has no money for universal vaccination

13. 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

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

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

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

17. 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?
?

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

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

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

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

24. 24
• 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, Go vindappag a ri, Pawar e t al, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bste t
G yne co l2 0 1 2; 1 20 : 7 7 1 – 8 2
Postpartum HPV Vaccination
Two Facts

25. 2 Studies
25
• 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 forcatch-up HPV vaccination in young women afterfirst delivery, J
Epidemiol Community Health 2010;64:610e615
2. Wright, Govindappagari, Pawaret al, Acceptance and Compliance With PostpartumHuman Papillomavirus
Vaccination, Obstet Gynecol2012;120:771–82

26. OPPORTUNITY FOR CATCH-
UP HPV VACCINATION IN
YOUNG WOMEN AFTER
FIRST DELIVERY
Rama et al (2006-07 ) Brazil
26
Primiparous 15 – 24 years

27. Results
27
Overall, HPV
DNA was
detected in
58.5% of the
women included
in the analysis
Rama, Villa, Pagliusi et al, Opportunity forcatch-up HPV vaccination in young
women afterfirst delivery, JEpidemiol Community Health 2010;64:610e615

28. 28
• 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 forcatch-up HPV vaccination in young women afterfirst
delivery, JEpidemiol Community Health 2010;64:610e615
Rama et al (2006-07 ) Brazil

29. 29
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
Rama et al (2006-07 ) Brazil

30. ACCEPTANCE AND
COMPLIANCE WITH
POSTPARTUM HUMAN
PAPILLOMAVIRUS
VACCINATION
Wright et al (2012)
30
Postpartum women 18 – 26 years (N150)
3 visits at delivery 1st
dose
6 weeks second dose
6 month 3 dose
Quadrivalent HPV Vaccine
Obstet Gynecol 2012;120:771–82

31. Materials & Methods
31
• 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

32. Results
32
• 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.
Wrig ht, Go vindappag ari, Pawar e t al, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bste t Gyne co l20 1 2;1 20 : 7 7 1 – 8 2
Wright et al (2012) Obstet Gynecol 2012;120:771–82

33. Results
33
• 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
Wrig ht, Go vindappag ari, Pawar e t al, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bste t Gyne co l20 1 2;1 20 : 7 7 1 – 8 2
Wright et al (2012) Obstet Gynecol 2012;120:771–82

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

35. 99% compliance
• Happy
• Convenient
• Recommended to her friends / Relative

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

37. Be true to your highest conviction !!

38. Thank You