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Post partum period an excellent opportunity for hpv vaccination
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  • 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
  • 7. How To Handle C E R V I C A L Cancer In India
  • 8. Why ca cervix not given importance Govt. in India?
  • 9. Screening – not even tip of iceberg
  • 10. Vaccination Famous Phase III trials HPV vaccines • FUTURE – Females Unites to unilaterally reduce Endo/ Ectocervical Disease • PATRICIA – Papilloma Trial Against Cancer In Young Adults
  • 11. 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
  • 12. 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
  • 13. Second Fact The efficacy of the vaccine against cervical disease is reduced among women who are HPV seropositive at the time of vaccine administration
  • 14. • 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
  • 15. Catch up Vaccination Is Thus a Big Challenge !!
  • 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
  • 18. 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
  • 19. POST-PARTUM PERIOD: AN OPPORTUNITY FOR HPV VACCINATION
  • 20. • Cerverix - Not recommended during pregnancy • Gardasil - Can be given in lactation period FOGSI Recommendations: Pregnancy and Lactation www.fogsi.org/hpv vaccine
  • 21. 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
  • 22. 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
  • 23. OPPORTUNITY FOR CATCH- UP HPV VACCINATION IN YOUNG WOMEN AFTER FIRST DELIVERY Rama et al (2006-07 ) Brazil 26 Primiparous 15 – 24 years
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. POST-PARTUM PERIOD : is excellent OPPORTUNITY FOR HPV VACCINATION Experience Of last two years (2011-13) (N – over 200)
  • 32. 99% compliance • Happy • Convenient • Recommended to her friends / Relative
  • 33. • 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
  • 34. Be true to your highest conviction !!
  • 35. Thank You