11. Life is like different apps & install
only which is useful.
12. Most exciting development in the
field of cervical cancer control
which is highly effective and safe.
New vistain cervical cancer
prevention for CATCH UP GROUP
HPV vaccination in the POST PARTUM period
13. Doctors have many DOUBTS
&
CONCERNS regarding
recommending HPV VACCINE
to Postpartum Patients
14. Let Me Place Few Facts
to plead for Post Partum HPV vaccination
Simple as Possible
15. Cervical Cancer
is big
‘Public Health concern’‘Public Health concern’
• Never received due attention either from
GOI or from the Doctors
• Not among the TOP national health
programs.
• Field level Screening & HPV
vaccinations is still very poor
16. This Cancer is 100% Preventable !!
HPV Vaccination
Regular screening – by pap smear
This strategy has offered
best possible protection against Cervical Cancer
In developed world
17. not even tip of iceberg
2.8% only
SCREENING
IN INDIA
18. GOI – has no budget
allocation
for
universal
vaccination
The vaccination rates for the target group
(Adolescent 9-13 yrs) is very very low
The level of awareness about
cervical cancer is poor in all
section of population
19. • Administration of HPV vaccine prior to
initiation of sexual activity provides the
greatest benefit
• Young girls seek preventive HPV vaccination
less frequently in india bcz it is NOT FREE.
• Opportunity for catch-up vaccination
in the post partum period is valuable
to improve coverage of vulnerable
populations.
Simple Facts
20. Motivation & Compliance is Easy
In The POSTPARTUM PERIOD
Family planning modus operandi is PPP
• Most receptive to advice
• One can take this opportunity to offer them HPV
vaccination
• Willing to spend for vaccination
Dr. Sharda Jain & team (2011-14)
21. Oncogenic HPV acquisition by age
The risk for infection/reinfection
remains throughout life
Age-specific incidence of infections with oncogenic HPV types
after an average interval of 14 months*– Ontario (Canada)
Sellors JW, et al. CMAJ 2003; 168:421–425.* Average interval between annual periodic health examinations
30
25
20
15
10
5
0
Incidencerate,%
15–19 20–24 25–29 30–34 35–39 40–44 45–48
22. Every woman is at risk of
Cervical Cancer !!!!
• 80% of females
get infected
with HPV by
the age of
50 years.
23. Prevalence of Exposure to Multiple
Vaccine HPV Types at Day 1
HPV 6, 11, 16
and/or 18
All subjects aged 24-45 (N = 3,819)
DNA Only DNA or Serology
n % n %
At least 1 type detected 298 7.8 1,252 32.8
Only 1 type detected 270 7.2 890 23.9
At least 2 types detected 28 0.7 362 9.5
Only 2 types detected 25 0.7 266 7.0
Only 3 types detected 3 0.1 82 2.1
All 4 types detected 0 0.0 14 0.4
n = number of subjects in indicated category.
1. Luna J, et al. Poster presented at: 28th International Papillomavirus Conference. November
30–December 6, 2012; San Juan, Puerto Rico. Poster EP-765-2.
24. 0%
20%
40%
60%
80%
100%
16–26 Years Old 24–45 Years Old
WomenVaccinatedWithGARDASIL
GARDASIL™
[Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine]
Estimated Benefit of Vaccination With GARDASIL
in Sexually Active Women
99.9% of
women will
benefit
99.6% of
women will
benefit
Women who have been exposed to at least 1 but not all vaccine-targeted HPV
types will derive some benefit from vaccination.1
1. Wright TC Jr et al. Gynecol Oncol. 2008;109(2 suppl):S40–S47. 2. Data on file, MSD ______. 3. Velicer C et al.
Sex Transm Dis. 2009;36:696–703.
Infected with all 4 types
Infected with 3 types
Infected with 2 types
Infected with 1 typeWomen unexposed to any
vaccine-targeted type
0.1% infected
with all 4
vaccine types
0.4% infected
with all 4
vaccine types
In clinical trials of GARDASIL
2 3
26. Results
Maximum incidence of
HPV infection in the 2-3 decade of life
Incidence of HPV DNA+ve pregnant
women in this study was 18 %.
27. Opportunity for catch-upOpportunity for catch-up
HPV vaccination in youngHPV vaccination in young
women after first deliverywomen after first delivery
Rama et al (2006-07) Brazil
27
2nd
Study
28. Results
28
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
Rama et al (2006-07 ) Brazil
29. The HPV prevalence (58.5%) found in the young primiparous women
• 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
• 17.3% were positive for HPV 16
and
• 13.3% were positive for HPV 18
30. 30
This study suggests and supports that young
population would definitely derive
benefit from catch-up vaccination in
postpartum period to protect against
cervical cancer
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
Take Home message
31. WRIGHT AND COLLEAGUES during the postpartum period
ACCEPTANCE AND COMPLIANCE
WITH POSTPARTUM HUMAN
PAPILLOMAVIRUS
VACCINATION
Wright et al (2012)
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
3rd Study
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.
Wright, Govindappagari, Pawar et al, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, Obstet Gynecol 2012;120:771–82
Wright et al (2012) Obstet Gynecol 2012;120:771–82
33. Results
33
Despite the acceptability of this strategy, only
30.7% of enrolled patients completed the three-
vaccine series
Counseling
&
counseling
35. POST-PARTUM PERIOD : is excellent
OPPORTUNITY FOR HPV VACCINATION
Experience
Of last FOUR YEARS (2011-14)
(N – over 520)
Briefing is done at 1st
antenatal visit
4thStudy
37. INDICATION
Females Aged 9 Through 45 years
"for prevention of cervical, vulvar, and
vaginal cancer, precancerous or
dysplastic lesions, genital warts, and
infections caused by Human
Papillomavirus (HPV) Types 6, 11, 16
and 18 (which are included in the
vaccine)."
QHPV
GARDASIL Approvals*: Adult Women IndicationGARDASIL Approvals*: Adult Women Indication
Approved in 52 countriesApproved in 52 countries
38. GARDASIL®
: FUTURE III: Adult Women Study
Combined Incidence of HPV 6/11/16/18-Related CIN2 or worse in Women 24–45 Years of Agea
a
Effectiveness in the early vaccination group after 3 doses in women 24–45 years of age naïve to the relevant type
at baseline in an extension study of FUTURE III trial in Columbia.
Per-Protocol Efficacy Population a
– Primary Endpoint
Related
Cases
1511
29
21
7
0
30
CIN & EGL or worse CIN or worse CIN 2 or worse
GARDASIL®
Expected cases
Total
Mean Follow-Up: 6.3 Years
1
20
10
1. Luna J, et al. Poster presented at: 28th International Papillomavirus Conference. November 30–December 6, 2012; San Juan, Puerto Rico. Poster EP-765-2.
High efficacy seen in
adult women
39. Value of Vaccinating
a Sexually Active (Catch-Up Cohort)1
• Reduction of:
–Number of women with cytological
abnormalities
–Number of women with CIN 2/3, VIN 2/3,
and
other related diseases
–Incidence of invasive cervical cancer
1. Wright TC Jr et al. Gynecol Oncol. 2008;109(2 suppl):S40–S47.
CIN = cervical intraepithelial neoplasia; EGLs = external genital lesions; VIN = vulvar intraepithelial neoplasia.
40. GARDASIL Placebo
%
Reduction 95% CI
ASC-US HR+
or Worse
1 38 97% 85, 100
ASC-US HR+ 1 13 92% 49, 100
LSIL 0 25 100% 84, 100
ASC-H 0 1 100% <0, 100
HSIL 0 0 – –
a
Efficacy after 3 doses in women 24–45 years of age naïve to the relevant type at baseline.
ASC-H = atypical squamous cells, cannot exclude HSIL; ASC-US = atypical squamous cells of undetermined
significance; CI = confidence interval; HR = high risk; HSIL = high-grade squamous intraepithelial lesions;
LSIL = low-grade squamous intraepithelial lesions.
GARDASIL™
[Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) Recombinant Vaccine]
Per-Protocol Efficacy Populationa
; Mean Follow-Up: 3.8 Years
1. Data on file, MSD ______.
GARDASIL: Adult Women Efficacy Study1
Reduction in HPV 16/18-Related Abnormal Pap Test Results
44. Post Partum Vaccination
• Lactating women
can receive the
HPV vaccine and
still continue
breast feeding
because it is a
vaccine without
live viral DNA.
45. • Dosage and Administration
– Vaccine should be shaken well before administration.
– Dose - 0.5 mL, Intramuscularly
– In the deltoid muscle or upper anterior thigh.
• Recommended Schedule
3-dose schedule (0-2-6)
• Minimum Dosing Intervals
First and second dose - 4 weeks
Second and third dose -12 weeks
Do’s & Don’ts
7. MMWR, March 12, 2007 / Vol. 56
46. • Is safe at the same visit such as Tdap,
Hepatitis B or Meningococcal vaccines
• Vaccines should be administered using a
separate syringe at a different anatomic site.
Simultaneous Administration of Other
Vaccines
47. To Conclude
• While taking care of your post- partum
patients Don’t miss out a HPV cervical Cancer
Vaccination
• talk to them today.
• Postpartum administration of the HPV
vaccine is feasible.
48. To conclude
• Most women prefer to receive the vaccine
while they are already in the hospital or at a
clinic appointment as opposed to making a
separate visit for vaccination.
• Post partum vaccination is associated with a
high degree of SATISFACTION among women.
• They are READY TO SPEND MONEY if briefed
in antenatal period
49. For Cervical Cancer Prevention
We
Gynaecologists
have a major
role to play to
offer post
partum HPV
vaccination
& make great difference To decrease
Ca. Cervix
50. • With the exception of clean drinking water ,
vaccines are most effective intervention to
reduce and prevent an infectious disease
• Today 26 diseases are vaccine
preventable
Let’s add cervical cancer to this list !!
Don’t forget
Every 7 minutes
1 Indian women dies of Ca Cx.
51. Be true to your highest conviction !!
Only way forward is catch-up
HPV vaccination at postnatal visits
52. ADDRESS
11 Gagan Vihar, Near Karkari
Morh Flyover, Delhi - 51
CONTACT US
9650588339, 011-22414049,
WEBSITE :
www.lifecarecentre.in
www.drshardajain.com
www.lifecareivf.com
E-MAIL ID
Sharda.lifecare@gmail.com
Lifecarecentre21@gmail.com
info@lifecareivf.com
&
Editor's Notes
Simple Facts
n = number of subjects with non-missing data; m = number of subjects in indicated category.