Cervical Cancer Vaccine - Do we need it in India
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  • Full Name Full Name Comment goes here.
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  • I did a google translation since I do not understand Indonesian ...
    This is what the query is 'Need assessment before deciding to use the HPV Vaccine?'
    The answer is NO,
    Since the protection is against more than 1 strain of the virus HPV, even if your patient is having changes related to cervix disease, they are still going to get protection against the other strains of HPV.
    Hence no need for prior testing.
    Of course regular testing should be continued as per protocol even after HPV vaccination.
    Thanks for taking the time out to read and comment :)
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  • Perlu pengkajian sebelum memutuskanmenggunakan Vaccine HPV???
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  • Global incidence The incidence of cervical cancer varies widely around the world, with the highest incidence in developing countries. Incidence rates exceeding > 30 cases per 100 , 000 population occur in Latin America and Sub-Saharan Africa with lower incidences observed in Western Europe, North America and Japan. The incidence rates for each country are available from the International Agency for Research on Cancer (IARC) database. The main reason for these variations in incidence is the availability of screening programmes in developed countries but not in poorer developing countries. Screening can detect the early signs of cervical cancer, allowing for prompt treatment to prevent the development of invasive and potentially fatal cervical cancer. It is important to understand that these figures are not necessarily accurate everywhere. They are sourced from World Health Organization and IARC data , which varies in quality depending on country. Data from Finland, for example, will be perfect because they have good records systems and all cancers are routinely reported. In India, by contrast, very few centres report into data sources and, in some areas of Africa, incidence figures are an estimate only because of the lack of availability of cancer registries or other reporting mechanisms . Likewise, t he incidence in China is reported to be low but this may be because of under-reporting . Reference Ferlay J, et al. GLOBOCAN 2002 Cancer Incidence, Mortality and Prevalence Worldwide. IARC CancerBase; Lyon, 2004 .
  • Message: Of all the HPV types that have been identified, only 4 account for approximately 80% of all cervical cancer cases. Transmission of HPV occurs by skin-to-skin contact HPVs infect the skin and mucous membranes, causing - Benign skin warts (papilloma) - Genital warts ( condyloma acuminata) - Precancerous cervical dyskaryoses - Cervical cancer – caused by “high risk” types of HPV Condoms reduce the risk of transmission, but do not prevent it Types HPV16 and HPV45 are closely related; Types HPV18 and 31 are closely related
  • The HPV lifecycle is restricted to the cervical epithelium; there is no viraemia. The virus is thought to infect the basal cell layer of the epithelium via microabrasions. It then uses the host cell machinery to replicate viral DNA and express virally encoded proteins. The HPV genome encodes eight genes: six encode the ‘early’ or nonstructural proteins (E1, E2, E4, E5, E6, E7); two encode the ‘late’ or structural proteins (L1, L2). Finally, new virus particles are assembled in the upper layers of the epithelium and virus is released with the cells as they are shed from the epithelial surface. Reference Frazer IH. Nat Rev Immunol 2004; 4: 46–54.
  • The process of cervical carcinogenesis is illustrated schematically here. After the cervix is infected with HPV, infection may cause mild Pap abnormalities and/or mild CIN, which usually clear spontaneously. Koilocytosis is a distinctive histological feature of HPV infection and is the appearance of halo or koilocytotic cells in the differentiated layers of the squamous epithelium. The koilocytes are squamous epithelial cells that contain an acentric, hyperchromatic nucleus that is displaced by a large perinuclear vacuole. 1 It has become clear that persistence of high-risk HPV is a key factor in the progression to precancerous lesions or high-grade dysplasia (CIN2/3) which has a greater likelihood of progression to invasion and cancer. 2,3 As shown, abnormal infected cells and CIN1 can also be termed low-grade squamous intraepithelial lesions (LSIL), while CIN2 and CIN3 can also be termed high-grade squamous intraepithelial lesions (HSIL). 3 The progressive development of cellular changes from HPV infection to cervical cancer generally takes 10–20 years, although , in very few cases , it may only take 1–2 years. 2 CIN1 changes can arise within 3 months of infection , CIN2 within 6 months and CIN3 within 1–2 years. References 1. Krawczyk E, et al, Am J Pathol 2008; 173: 682–688 2. Burd EM. Clin Microbiol Rev 2003; 16: 1–17. 3. Solomon D, et al. JAMA 2002; 287: 2114–2119.
  • Secondary prevention of cervical cancer
  • Impact of HPV vaccination on screening practices
  • An overview of key points which will be covered in more detail later in this section is provided. Virus-like particles (VLPs) of HPV 16 and 18 were chosen because these HPV types are most frequently associated with cervical cancer worldwide. Capsid proteins self-assemble into VLPs which are highly immunogenic because they closely mimic the virus. When used together with an effective adjuvant system, they elicit a high and sustained immune response.
  • An overview of key points which will be covered in more detail later in this section is provided. Virus-like particles (VLPs) of HPV 16 and 18 were chosen because these HPV types are most frequently associated with cervical cancer worldwide. Capsid proteins self-assemble into VLPs which are highly immunogenic because they closely mimic the virus. When used together with an effective adjuvant system, they elicit a high and sustained immune response.
  • Comparison of antigen/adjuvant content of the two vaccines.
  • This slide describes Cervarix’s innovative adjuvant, AS04. AS04 consists of monophosphoryl lipid A (MPL) adsorbed onto the antigen carrier aluminium hydroxide. MPL is a purified lipopolysaccharide from a bacterial wall and is a powerful stimulant of the immune system. The combination of the highly purified and immunogenic VLP antigens with the AS04 adjuvant system provides a strong vaccine immunogen leading to an immune response which is enhanced when compared with traditional adjuvants. Reference Garcon N. Development and evaluation of AS04, a novel and improved adjuvant system containing MPL and aluminum salt. In: Immunopotentiators in modern vaccines, 2005; pp. 161–178. Edited by: Schijns V, O’Hagan D. London: Academic Press.
  • Cervarix ® : HPV 16/18 efficacy profile up to 7.3 years (Phase IIb, women aged 15–25 years) Up to 7.3 years, none of the subjects in the vaccine group developed HPV 16- or 18-related CIN2+ over the study period. References Harper D, et al. Lancet 2004; 364: 1757–1765. Harper D, et al . Lancet 2006; 367: 1247–1255. Gall S. AACR 2007; Abstract. Harper D, et al. Gynecol Oncol 2008; 110 (Suppl 1) : S11-S17 . GlaxoSmithKline Vaccine HPV-007 Study Group . Lancet 2009; 374: 1975–1985 . Carvalho ND, et al . ESGO 2009; Abstract.

Cervical Cancer Vaccine - Do we need it in India Cervical Cancer Vaccine - Do we need it in India Presentation Transcript

  • Cervical Cancer Vaccine – Do WE need it? Dr Gaurav Gupta, (Ex PGI) Practising Pediatrician, Charak Clinics, Mohali Member AAP, IAP.
  • Points to be discussed
    • HPV – Natural History & Epidemiology
    • Cervical Cancer – the Indian Context
    • Preventing Cervical Cancer – other options
    • Need for vaccination against Cervical Cancer
    • Vaccine Efficacy & Safety
    • Vaccine – the Indian experience
    • IAP / FOGSI recommendations
  • Cervical Cancer & HPV – Epidemiology & Natural History
    • 500,000 women diagnosed per year 1
    • 270,000 deaths per year 1
      • >1 million new cases of cervical cancer each year, 2050 2
    • 1 out of 4 women who die due to Cervical Cancer in the world is an Indian 3
    Global Burden of Cervical Cancer 1. Ferlay J, et al. GLOBOCAN 2002 Cancer Incidence, Mortality and Prevalence Worldwide. IARC CancerBase; Lyon, 2004; 2. Parkin DM, et al. Eur J Cancer 2001; 37 (Suppl 8):S4-S66. 3. GLOBOCAN 2008
  • In India, over 72000 women die every year due to Cervical Cancer
    • Every year 134000 Indian women are diagnosed with Cervical cancer and around 72000 die from the disease
    • Cervical cancer ranks No. 1 among cancers in Indian women, that’s even more than Breast Cancer
    GLOBOCAN 2008 Cancer Incidence, Mortality andPrevalence India
  • HPV infection is a necessary cause for Cervical Cancer Adapted from Parkin DM & Bray F. Vaccine 2006; 24 (Suppl 3):S11. Walboomers JMM, et al. J Pathol 1999; 189: 12–19. * Global total HPV-attributable cancers in 2002 Attributable to HPV Site Total cancers % Cases Cervix 492,800 100 492,800 Vulva, vagina 40,000 40* 16,000 Anus 15,900 90* 14,300 Oropharynx 9,600 12* 1,100 Mouth 98,400 3* 2,900 Total 527,100
  • Human Papillomavirus (HPV) In India 4 HPV Types: HPV 16, 18, 31 and 45 are responsible for >90% Squamous Cell Carcinoma 2 >95% Adenocarcinoma 2 100 HPV Types Have Been Identified 1 30 HPV Types are Transmitted by Genital skin to skin Contact 15 HPV Types are Oncogenic
    • Munoz N et al. N Engl J Med 2003; 348(6):518-527
    • 2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010.
  • Adenocarcinoma of the cervix- An Emerging concern
    • HPV 16, 18, 45 and 31 are responsible for >95% of Adenocarcinoma in India 1,2
    • Adenocarcinoma is difficult to detect with routine screening methods 1
    • Incidence increasing (20–25% of all cervical cancers 3,4
    • More aggressive and occurs in younger women 3,4
    • WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010.
    • 2. Bhatla N et al. Vaccine 2008; 26(23):2811-2817.
    • 3. Bosch FX, et al. Vaccine 2008; 26S:K1–K16; 4.Castellsague X , et al. JNCI 2006; 98: 303–315 .
    Adenocarcinoma: may be inaccessible to the cervical smear brush Squamous cell carcinoma : usually accessible to the cervical smear brush
  • HPV Lifecycle in the Cervix Normal epithelium Basement membrane Basal (stem) cells Parabasal cells Squamous layer Mature squamous layer Infected epithelium Cervical canal Frazer IH. Nat Rev Immunol 2004; 4: 46–54.g
  • Progression of Cervical Disease Time Years Months Normal epithelium * With increasing probability of viral DNA integration CIN=cervical intraepithelial neoplasia; ASCUS=atypical squamous cells of undetermined significance Burd EM. Clin Microbiol Rev 2003; 16: 1–17; Solomon D, et al. JAMA 2002; 287: 2114–2119 Invasive carcinoma High-grade squamous intraepithelial lesion (HSIL) CIN2 CIN3 Low-grade squamous intraepithelial lesion (ASCUS/LSIL) HPV infection koilocytosis CIN1 Regression Progression*
    • HPV infections are very common and u p to 80% of women will acquire an HPV infection in their lifetime 5 –7
    • The risk of oncogenic HPV infection is high even after first intercourse and continues throughout a woman’s sexually active lifetime 2–4
    • Although new infections decrease with age, risk of their persistence increases with age 8
    • The cumulative risk of acquiring cervical HPV infection in women with only one sexual partner is 46% (3 years after first sexual encounter) 1
    Every woman is at risk of Cervical Cancer 1. Collins S, et al. Br J Obstet Gynaecol 2002; 109: 96–98; 2. Schiffman M, et al. J Natl Cancer Inst 2003; 31: 14–19; 3. Sellors JW, et al. CMAJ 2003; 168: 421–425; 4. Dunne EF, et al. JAMA 2007; 297: 813–819; 5. Brown DR, et al. J Infect Dis 2005; 191: 182–192; 6. Koutsky L, et al. Am J Med 1997; 102: 3–8; 7. Bosch FX, et al. J Natl Cancer Inst Monogr 2003; 31: 3–13; 8. Castle PE, et al. J Infect Dis 2005; 19: 1808–1816. 8. Castle PE, et al. J Infect Dis 2005; 191: 808–816;
  • HPV Clinical Features
    • Most HPV infections are asymptomatic and result in no clinical disease
    • Clinical manifestations of HPV infection include:
      • anogenital warts (2-25.2% of STI clinic in India)
      • recurrent respiratory papillomatosis
      • cervical cancer precursors (cervical intraepithelial neoplasia)
      • Cancer (cervical, anal, vaginal, vulvar, penile, and some head and neck cancer)
    • Cervical Cancer – the Indian Context
  • CERVICAL CANCER
    • Estimated new cases and deaths from cervical (uterine cervix) cancer in the United States in 2009:
      • New Cases: 11,270
      • Deaths: 4,070
    • India
      • New Cases: 1,32,000
      • Deaths: 74,000
    • In India Cervical cancer ranks No. 1 among cancers in women followed by breast cancer
    • Every year 132000 Indian women are diagnosed with Cervical cancer and around 74000 die from the disease
    Cervical Cancer is more common than Breast Cancer, in India GLOBOCAN 2002 Cancer Incidence, Mortality andPrevalence India
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    • Preventing Cervical Cancer – other options
    • Cervical screening (traditionally using the Pap smear and more recently by liquid-based cytology [LBC]) is used to detect existing cervical abnormalities and precancerous disease 1
    • Neither method offers primary prevention; HPV infection and development of cervical disease can still occur
      • Deaths from cervical cancer still occur in countries with established screening programmes 2
    • Vaccination offers an important new management option in the primary prevention of cervical cancer
    Cervical Cancer Prevention 1. Sankaranarayanan R, et al. Int J Gynaecol Obstet 2005; 89 (Suppl 2) : S4–S12; 2. WHO/ICO Information Centre on Human Papilloma Virus (HPV) and Cervical Cancer. Available at: http://www.who.int/hpvcentre/statistics (accessed February 2010) .
  • Impact of HPV vaccination on screening practices
    • In countries without existing screening programmes
      • Modelling studies suggest that vaccination is likely to be the most effective option to reduce the incidence of cervical cancer 2,4
    • In countries with established screening programmes
      • HPV vaccination + screening is predicted to be more effective and cost-effective than screening alone for the prevention of cervical cancer and cervical pre-cancer 1,2, 3
      • Screening should continue in order to detect disease related to non-vaccine HPV types
        • Screening intervals are likely to increase once widespread vaccination occurs
    1. Garnett GP, et al. Vaccine 2006; 24 (Suppl 3) : S178–S186; 2. Goldie SJ, et al. J Natl Cancer Inst 2004; 96: 604–615; 3. Elbasha EH, et al. Emerg Infect Dis 2007; 13: 28–41; 4. Goldie SJ, et al. Int J Cancer 2003; 106: 896–904.
  • HPV AND WOMEN
      • Treatment for HPV related cervical abnormalities:
        • Colposcopys, cervical biospsies, cryotherapy, laser treatment, LEEP.
    • New opinions often appear first as jokes and fancies, then as blasphemies and treason, then as questions open to discussion, and finally as established truths
            • George Bernard Shaw
  • PREVENTION OF HPV
    • Primary Prevention: Vaccination
    • Secondary Prevention: Screening Program including regular PAP smear tests
    Harald zur Hausen Born March 11, 1936   (age   74) Germany Nationality German Known   for Discovery that   HPV   can cause cervical cancer Notable awards 2008   Nobel Prize in Physiology or Medicine
  • The need for Vaccination against Cervical Cancer
  • 1.Stanley M. Vaccine 2006; 24: S106-13, 2.Tindle, Nat Rev Cancer 2002; 2, 59, 3.Stanley M. Vaccine 2006; 24: S16-22, 4. Stanley M. HPV Today 2007; 11: 1-16 No viremia Local immunosuppression No inflammation, no danger signals Natural HPV infection induces a weak immune response 1-4
  • 1. Parr EL et al. J Virol 1997;71(11):8109-15, 2. Nardelli-Haefliger D et al. J Natl Cancer Inst 2003;95(15):1128-37, 3. Schiller JT et al. Nat Rev Microbiol 2004;2(4):343-7, 4. Poncelet et al. ESPID, Porto, Portugal 2007; Abstract 37, session ES2, 5. Stanley M. HPV Today 2007; 11: 1-16, 6. Einstein M, Cancer Immunol Immunother 2007; 57(4):443-51. Vaccination induces higher antibodies in the blood and site of infection
    • Vaccine induces higher antibody levels in the blood which means higher antibody levels at the site of infection 4
    • These Antibodies neutralize the virus & prevent entry into cells 5,6
  •  
  • What makes a good cervical cancer vaccine?
    • Antigens (virus-like particles) that closely mimic the virus structure
    • Generation of neutralizing antibodies – the major basis of protection
    • High levels of antibodies in the serum that can transude to the site of infection
    • Induce long lasting protection
  • What makes a good cervical cancer vaccine?
    • Antigens which closely mimic the virus
    • Adjuvants for the generation of high levels of neutralizing antibodies
    HPV-containing double stranded DNA ‘ Empty’ non-infectious virus-like particle (VLP) mimics the virus
  • The adjuvant concept
    • Adjuvants enhance the specific immune response to vaccine antigens 1
      • Efficient antigen delivery – depot effect
      • Mimic danger signals & stimulate innate immunity through pro-inflammatory cytokines
    • Adjuvants currently used in Cervical Cancer vaccines:
      • Aluminium salts (Gardasil®)
      • AS04 (Monophosphoryl-Lipid A + Al(OH) 3 ) ( Cervarix TM )
    Vaccines, 5 th edition, 2008 Stanley Plotkin
  • Composition of the two licenced HPV vaccines Gardasil ® Non- Oncogenic Antigens Aluminium salt + HPV 16 VLPs HPV 18 VLPs Oncogenic Antigens AS04 + Aluminium salt MPL (Immuno Stimulant) Cervarix TM + HPV 16 VLPs HPV 18 VLPs HPV 6 VLPs HPV 11 VLPs Oncogenic Antigens Adjuvant
  • AS04: Novel adjuvant system in Cervarix™ High and Lasting levels of Antibodies and Memory B cells Highly purified antigens Enhanced immune response AS04 Aluminium salt MPL (Immuno Stimulant) AS04 Garcon N. Development and evaluation of AS04, a novel and improved adjuvant system containing MPL and aluminum salt. In: Immunopotentiators in modern vaccines, 2005; pp. 161–178. Edited by: Schijns V, O’Hagan D. London: Academic Press. + Strong immunogens
    • Twenty years from now you will be more disappointed by the things that you didn't do than by the ones you did do. Explore. Dream. Discover.
      • Mark Twain
    • Higher antibody titres were detected in the serum in those women who recieved Cervarix compared to those who recieved Gardasil
    • Higher antibody titres were detected at the Cervix in those women who recieved Cervarix compared to those who recieved Gardasil
    • The memory B-cell responses were also higher with Cervarix than Gardasil for both antigens
    Summary: Comparison of the immunogenicity of Cervarix ™ and Gardasil ® Einstein MH, Baron M, Levin MJ, Chatterjee A, Edwards RP, Zepp F, et al. Comparison of the immunogenicity and safety of Cervarix() and Gardasil((R)) human papillomavirus (HPV) cervical cancer vaccines in healthy women aged 18-45 years. Hum Vaccin 2009 Oct 14;5(10).
  • Cervarix™ : 100% efficacy against HPV 16/18 year after year 1. Harper D, et al. Lancet 2004; 364: 1757–1765; 2. Harper D, et al . Lancet 2006; 367: 1247–1255; 3. Gall S, et al. AACR 2007; Abstract; 4. Harper D, et al. SGO 2008 ; Abstract; 5. GlaxoSmithKline Vaccine HPV-007 Study Group . Lancet 2009; 374: 1975–1985; 6. Carvalho ND, et al . ESGO 2009; Abstract. HPV 16/18-related CIN2+ Cervarix ® Control Vaccine efficacy n n % 95% CI Initial efficacy study 2.3 years 1 0 3 NA* NA* Combined analysis of initial efficacy study and extended follow-up 4.5 years 2 0 5 100.0 -7.7–100.0 5.5 years 3 0 7 100.0 32.7–100.0 6.4 years 4,5 0 9 100.0 51.3–10.00 7.3 years 6 100.0 -129.9–100.0 * The initial efficacy study was not powered to calculate vaccine efficacy against histopathologically confirmed CIN. n = number of subjects reporting at least one event in each group. ITT analysis.
  • HPV Vaccine Adverse Reactions
    • Local reactions commonest
    • (pain, swelling)
    • Syncope – Give vaccine in sitting / lying down position, and observe for 15 minutes after vaccination
    • No serious adverse reactions reported
    *similar to reports in placebo recipients (9%)
  • HPV vaccines: Safety and approval
    • WHO’s Global Advisory Committee on Vaccine Safety (GACVS) concluded that the HPV vaccines had good safety profiles 1
    • U.S. Food and Drug Administration (FDA) approved Cervarix™ on 15 October 2009 2
    1. http://www.who.int/wer/2009/wer8415.pdf. (Accessed Feb 2010) 2. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm186959.htm. (Accessed Feb 2010)
    • Immunogenicity and safety of human papillomavirus-16/18 AS04-adjuvanted cervical cancer vaccine in healthy Indian women
    HPV Vaccine Study of Cervarix ™ in India Bhatla N et al. J. Obstet. Gynaecol. Res. Vol. 36, No. 1: 123–132, February 2010
  • Study Design
    • 354 women recruited in 4 centres in India
      • - PGIMER, Chandigarh
      • - All-India Institute of Medical Sciences, New Delhi
      • - Chittananjan National Cancer Institute, Kolkata
      • - Tata Memorial Hospital, Mumbai
    • Women aged 18-35
    • Doses given 0,1,6 months
    • Double-blind, 1:1 randomization Vaccine: Placebo (aluminum hydroxide)
    • ELISA testing of sera + safety & reactogenicity at 7 months
    Bhatla N et al. J. Obstet. Gynaecol. Res. Vol. 36, No. 1: 123–132, February 2010
  • Results
    • 100% Seroconversion / seropositivity of vaccine group
    • No difference for safety of vaccine vs. placebo
    • Commonest solicited Adverse Events:
      • Injection site pain, redness, swelling – all of which resolved
    • The AS04-adjuvanted HPV-16/18 cervical cancer vaccine (Cervarix™) was highly immunogenic and generally well-tolerated .
    Bhatla N et al. J. Obstet. Gynaecol. Res. Vol. 36, No. 1: 123–132, February 2010
  • Potential impact of HPV Vaccination
    • HPV vaccination is the primary prevention strategy against cervical cancer
    • HPV vaccination is predicted to have a major impact on the burden of cervical cancer, especially in settings without optimal screening programs
    • Paavonen J et al. Final Phase III Efficacy Analysis Of Cervarix™ In Young Women Abstract presented at the 25 th International Papillomavirus conference, Malmo, Sweden, 8-14 May 2009 2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in India. Summary Report 2010.
    • Cervical cancer causes significant morbidity/ mortality
    • HPV vaccine to be offered to all appropriate females who can afford the vaccine
    • Vaccine should be given prior to sexual debut
    FOGSI & IAP Recommendations www.fogsi.org/hpv vaccine
    • Age for initiation of vaccination is 10- 12 years.
      • Catch up vaccination is permitted up to the age of 26 years for quadrivalent & 45 yrs for bivalent vaccine
    • 3 doses at 0, 2 and 6 months with quadrivalent vaccine
    • 3 doses 0, 1 and 6 months with bivalent vaccine
    • No need for Booster doses
    FOGSI & IAP Recommendations– Vaccine Schedule www.fogsi.org/hpv vaccine
    • 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
    FOGSI Recommendations: Vaccination of Sexually Active Women www.fogsi.org/hpv vaccine
    • The vaccine can be given to patients with previous CIN, but the benefits may be limited to the protection against infection of HPV genotypes (and related CIN) with which they have not been infected
    • The HPV vaccine is not therapeutic. It does not treat existing HPV infection or cervical intraepithelial neoplasia (cervical pre-cancers)
    FOGSI Recommendations: Women With Previous CIN www.fogsi.org/hpv vaccine
      • Not recommended for use in pregnancy
      • If patient becomes pregnant - Delay remaining doses till delivery
      • If vaccinated during pregnancy - No intervention (MTP) needed
      • Lactating women can receive the HPV vaccine and still continue breastfeeding as it is a vaccine without live viral DNA
    FOGSI & IAP Recommendations: Pregnancy & Lactation www.fogsi.org/hpv vaccine
    • Vaccinated women should be screened as per the standard guideline
    • Screen positive women may be vaccinated after counseling
    • Screening/ HPV test is not required prior to vaccination
    FOGSI & IAP Recommendations: Vaccination & Screening www.fogsi.org/hpv vaccine
    • Vaccination: One of greatest public health achievements in the world
    • With the exception of clean drinking water, vaccines are the most effective intervention in reducing and preventing the return of infectious disease 1
    • 26 diseases are now vaccine preventable 2
    Value of vaccination Today 1 - European Vaccine Manufacturer’s paper 2003 2 - International Federation of Pharmaceutical Manufacturing Associations. May 2003 Let’s add Cervical Cancer to this list!