Post Partum Vaccination Dr. Jyoti Agarwal, Dr. Sharda jain

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Post Partum Vaccination Dr. Jyoti Agarwal, Dr. Sharda jain

  1. 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. 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. 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. 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. 5. We also Know the STRATEGY This cancer is 100% Preventable !! Regular screening vaccination offers best possible protection against Cervical Cancer
  6. 6. How To Handle C E R V I C A L Cancer In India
  7. 7. Vaccination Famous Phase III trials HPV vaccines • FUTURE – Females Unites to unilaterally reduce Endo/ Ectocervical Disease • PATRICIA – Papilloma Trial Against Cancer In Young Adults
  8. 8. Universal Vaccination GOI – has no money for universal vaccination
  9. 9. 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
  10. 10. Second Fact The efficacy of the vaccine against cervical disease is reduced among women who are HPV seropositive at the time of vaccine administration
  11. 11. 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
  12. 12. Catch up Vaccination Is Thus a Big Challenge !!
  13. 13. 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.
  14. 14. 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
  15. 15. 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?
  16. 16. *Knee jerk reaction* Should we err on side of caution or hope ? Medical Knowledge is always Incomplete and ambiguous
  17. 17. 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
  18. 18. POST-PARTUM PERIOD: AN OPPORTUNITY FOR HPV VACCINATION
  19. 19. FOGSI Recommendations: Pregnancy and Lactation • Cerverix - Not recommended during pregnancy • Gardasil - Can be given in lactation period www.fogsi.org/hpv vaccine
  20. 20. 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
  21. 21. 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
  22. 22. 25 OPPORTUNITY FOR CATCHUP HPV VACCINATION IN YOUNG WOMEN AFTER FIRST DELIVERY Primiparous 15 – 24 years Rama et al (2006-07 ) Brazil
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Experience Of last two years (2011-13) (N – over 200) POST-PARTUM PERIOD : is excellent OPPORTUNITY FOR HPV VACCINATION
  31. 31. 99% compliance • Happy • Convenient • Recommended to her friends / Relative
  32. 32. 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
  33. 33. Be true to your highest conviction !!
  34. 34. Thank You

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