HPV inefection , HPV disease prevention, Cervical cancer prevention , Cervical cancer treatment, Female cancer , Female cancer prevention , Uterine cancer , Cancer in india

1. Burden of HPV Infection /
Cervical Cancer &
Its Impact in India
DR. SHARDA JAIN
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar

2. Review this Lecture and others at:
Slideshare.net/lifecarecentre
Burden of HPV Infection / Cervical
Cancer & Its Impact in India

3. 3
Take home messages of 2 symposium on
Burden of HPV infection and cervical cancer
Delhi 4/7/2015

4. Presentation Outlines
• Introduction to Human Papillomavirus
• Acquisition of HPV infection
• Burden of cervical cancer and HPV
infection

5. Human Papillomavirus
• Papillomaviridae family, ds-DNA genome, non-
enveloped, icosahedral capsid with major (L1) and
minor (L2) structural proteins
• Persistent infection by oncogenic HPV types is a
prerequisite for the development of cervical cancer
• >190 types of HPV, 12 high-risk type for human
cancers, type 16 and 18 responsible for ~70% of all
cervical cancers in women globally
• Natural infection does not offer full protection
against new HPV infection
L1 protein pentamer
L2 supporting protein
Circular DNA
55 nm

6. 40
7 32
42
39
59
5544
PCV1
13
11
6
73
34
61
27
2a
57
3
28
10
29
51
26 30
53
56
66
RhPV1
70
18
45
58
33
52
1635
31
Papillomavirus Phylogenetic Tree
• The alpha-papillomavirus genus of the papillomavirus phylogenetic tree is
shown*
• Oncogenic types closely related to HPV 16 and 18 are highlighted
• HPV 16 is most closely related to HPV 31
• HPV 18 is most closely related to HPV 45
• Selected species and types are shown.

7. Acquisition of HPV Infection
• HPV infections can be acquired at any age.1-2,5 The risk starts from
sexual debut and continues throughout life.3
• Although new infections decrease with age, risk of persistence
(necessary condition for cervical cancer) increases.4 It puts adults
at risk.
• Penetrative intercourse is not necessary to become infected.6-7
HPV may be acquired by genital skin-to-skin contact.6
• Condoms do not fully protect against HPV transmission but
reduce the risk of infection.6-9
1. Gravitt PE et al. Infect Dis Clin North Am 2005; 19: 439–58; 2. Bosch FX et al. J Clin Pathol 2002; 55: 244–65; 3. Burk RD. Hosp Pract (Off Ed)
1999; 34: 103–11; 4. Castle PE et al. JID 2005;191:1806-16; 5. Franco EL et al. Vaccine 2005; 23:2388–94; ; 6. McIntosh N. Human
papillomavirus and cervical cancer. JHPIEGO 2000; 7. Partridge JM et al. Lancet Infectious Diseases 2006; 6: 21–31; 8. Winer RL et al. NEJM
2006; 354:2645-54; 9. Grainge MJ et al. Emerg Infect Dis. 2005; 11:1680-5.

8. Global total HPV-attributable cancers in females, 2002
Site
Total
cancers
Attributable to
HPV
% all
HPV
cancer
in
females
Attributable to HPV
16/18
% Cases % Cases
Cervix 492,800 ~100 492,800 93.5 70+ 344,900
Anus 15,900 90 14,300 2.7 92 13,100
Oropharynx 9,600 12 1,100 0.2 91 1,000
Mouth 98,400 3 2,900 0.6 97 2,800
Vulva, vagina 40,000 40 16,000 3.0 80 12,800
Total 527,100 374,600
HPV is a Necessary Cause for Cervical Cancer as virtually all cervical cancers
are caused by HPV.
HPV and Cervical Cancer
Adapted from Parkin DM & Bray F. Vaccine 2006; 24:S11–S25; Walboomers JMM, et al. J Pathol 1999; 189:12–19.

9. CIN3 is the immediate precursor of invasive cancer- Used as a better proxy
indicator for HPV vaccine efficacy .
Invasive
carcinoma
Normal
epithelium
HPV infection
koilocytosis
CIN1
3m
CIN2
6m
CIN3
12-24m
YearsMonths
PROGRESSION*
LSIL/ASCUS HSIL
REGRESSION ( ~1-2 Yrs)
HPV Infection to Cervical Cancer
57% 43% 32%
Burd. Clin Microbiol Rev 2003;16:1–17; Solomon et al. JAMA 2002;287:2114–2119

10. Burden of cervical HPV infection
HPV prevalence (%) in the general population (among
women with normal cytology)
7.9
Prevalence (%) of HPV 16 and/or HPV 18 among women with:
Normal Cytology 6
Low-grade cervical lesions (LSIL/CIN-1) 28.2
High-grade cervical lesions (HSIL//CIN-2/CIN-3/CIS) 56..5
Cervical cancer 84.1
Data sources: Bhatla N, Int J Gynecol Pathol 2006;25:398; Franceschi S, Int J Cancer 2003;107:127; Gheit T, Vaccine
2009;27:636; Munirajan AK, Gynecol Oncol 1998;69:205; Nagpal JK, Eur J Clin Invest 2002;32:943; Peedicayil A, Int
J Gynecol Cancer 2006;16:1591; Sowjanya AP, MBC Infect Dis 2005;5:116.
http://apps.who.int/hpvcentre/statistics/dynamic/ico/country_pdf/IND, p 28. Accessed on Nov 30, 2014
Burden of HPV Infection in India-
CIN, cervical intraepithelial neoplasia; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion;
CIS, changes in situ
1

11. Burden of HPV Infection in India-
Adapted from Bruni L et al. Summary Report 2014-12-18 p.39. Available at:
http://www.hpvcentre.net/statistics/reports/IND.pdf (Accessed on Feb 08, 2015).
Site Study Prevalence (%)
New Delhi Gupta 2009, Bhatla 2008, Arora 2005 16.6, 7.6, 10.0
North India Singh 2009 10.1
Chandigarh Aggarwal 2006 36.9
Lucknow Pandey 2012 (d) 11.7
Varanasi Srivastava 2012 (d) 9.7
Kolkata Mittal 2014 (d), Sankaranarayanan 2004 4.6, 7.8
WB Basu 2013 (d), Sarkar 2011 (e), Laikangbam 2007 5.8, 9.7, 11.6
Mumbai Kerkar 2011, Sankaranarayanan 2004 8.1, 6.3
TN Vinodhini 2012, Franceschi 2015 30.4, 14.0
East India Dutta 2012 9.2
Sikkim Laikangbam 2007 11.1
Manipur Laikangbam 2007 6.7
Prevalence of HPV among women with normal cytology in India, by study
d=Women from the general population, including some with cytological cervical abnormalities. e=Few HPV types tested: 16, 18 only.
2

12. An Airbus-320 full of WOMEN crashing every day in India
Deaths Due to CaCx - Just Think !

13. Burden of Cervical Cancer- in India
0
10CervicalCancerMortalityper100,000
20
30
50
15-19
Age Group in Years
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
=>75
India
South Asia
World
Estimated age-specific mortality of
cervical cancer in India, 2012
40
• Globally 528,000 cases of cervical
cancers (CaCx). It kills 266,000
women each year
• In India, every year 122,844 cases
and 67,477 deaths
• 334 cases per day and 185 deaths
everyday
• HPV 16 and/or 18 is responsible
for 83%
• It ranks as 2ND most common
cancer in women aged 15 to 44
years in India
1
Bruni L et al. Summary Report 2014-12-18. Available at:
http://www.hpvcentre.net/statistics/reports/IND.pdf (Accessed on Feb 08, 2015).

14. Burden of Cervical Cancer- in India
Incidence of cervical cancer compared to other cancers in women of all ages in India
2
Bruni L et al. Summary Report 2014-12-18. Available at:
http://www.hpvcentre.net/statistics/reports/IND.pdf (Accessed on Feb 08, 2015).

15. Burden of CaCx from Cancer Registry
Bruni L et al. Summary Report 2014-12-18 (p6-7). Available at:
http://www.hpvcentre.net/statistics/reports/IND.pdf (Accessed on Feb 08, 2015).

16. Burden of CaCx: Latest Publication, 2015
Sreedevi A et al. Int J Womens Health 2015;7:405-14
Age adjusted incidence rates of CaCx in female (rate per 100,000)

17. Appeal to Govt. Of India
CaCx: The Forgotten Killer in India
Annual Deaths
Mortality Trend
Priority in MDG
Current Investment in
Developing World
Maternal Mortality* Cervical Cancer **
50,000 Annually 67,000 Annually
- 38%, 1990-2008 + 50%, 1990-2008
YES, MDG-5 NO
USD 12 Billion,
Globally
???
MDG, Millennium Development Goal.
*Trends in maternal mortality: 1990 to 2013Estimates by WHO, UNICEF, UNFPA,
The World Bank and the United Nations Population Division

18. 18
NOW !!!

19. 19
THANK
YOU
SYMPOPSIUM
DELHI
4/7/2015
DR. SHARDA JAIN DR. SHYAM KUKREJA

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