Vagina and uterus lie behind and above the pubic bone in the pelvis. Urinary bladder and urethra are in front of the vagina and uterus, and the rectum is behind them. Ureters lie close to the cervix on each side.
India’s population is approximately 1/6th of the world burden but the disease burden in India is more than 25%( 1/4th)
Key Point Because HPV infection is common and usually asymptomatic, most transmission may occur unknowingly. HPV infection is usually transmitted by sexual contact, commonly through sexual intercourse, although transmission can occur through nonpenetrative genital contact. Background The greatest behavioral risk for the acquisition of HPV infection is sexual contact, specifically the rate of new partners per month.1,2 Sexual intercourse is important in the transmission of HPV.2 Other types of genital contact (genital–genital, manual–genital, oral–genital), which may begin at an earlier age than penetrative intercourse, may also lead to HPV infection.1,3,4 A recent US study of 603 college-aged (19 years of age, average age at enrollment) women reported a 2-year genital HPV incidence rate of 39% among sexually active women and 8% among virginal women.1 Genital HPV infection in virgins is rare, but may result from nonpenetrative sexual contact.1 Proper condom use may help reduce the risk of genital warts, CIN 2 or CIN 3, and invasive cervical cancer, but is not fully protective against infection.5 Other nonsexual routes of HPV infection include vertical transmission (from a mother to a newborn baby), although this is rare.6 A potential consequence of vertical transmission of HPV is recurrent respiratory papillomatosis (RRP), epithelial growths in the respiratory tract. In the larynx, growths may cause hoarseness and airway obstruction, which is potentially fatal. This condition presents most often in children younger than 5 years of age; but it can also occur in adults.7 Transmission of HPV infection may occur via contact with fomites, such as undergarments, surgical gloves, and biopsy forceps. This route of transmission has been hypothesized but is not well documented and would be rare.8,9 Although it is clear that sexual contact is the major mode of HPV transmission, most individuals infected by HPV do not know they have the disease.10 Therefore, they may unknowingly spread the virus. References 1. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university students. Am J Epidemiol. 2003;157:218–226. 2. Kjaer SK, Chackerian B, van den Brule AJ, et al. High-risk human papillomavirus is sexually transmitted: Evidence from a follow-up study of virgins starting sexual activity (intercourse). Cancer Epidemiol Biomarkers Prev. 2001;10:101–106. 3. Fairley CK, Gay NJ, Forbes A, Abramson M, Garland SM. Hand–genital transmission of genital warts? An analysis of prevalence data. Epidemiol Infect. 1995;115:169–176. 4. Herrero R, Castellsagué X, Pawlita M, et al. Human papillomavirus and oral cancer: The International Agency for Research on Cancer multicenter study. J Natl Cancer Inst. 2003;95:1772–1783. 5. Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia? A meta-analysis. Sex Transm Dis. 2002;29:725−735. 6. Smith EM, Ritchie JM, Yankowitz J, et al. Human papillomavirus prevalence and types in newborns and parents: Concordance and modes of transmission. Sex Transm Dis. 2004;31:57–62. 7. Kashima HK, Mounts P, Shah K. Recurrent respiratory papillomatosis. Obstet Gynecol Clin North Am. 1996;23:699–706. 8. Ferenczy A, Bergeron C, Richart RM. Human papillomavirus DNA in fomites on objects used for the management of patients with genital human papillomavirus infections. Obstet Gynecol. 1989;74:950–954. 9. Roden RB, Lowy DR, Schiller JT. Papillomavirus is resistant to desiccation. J Infect Dis. 1997;176:1076–1079. 10. Anhang R, Goodman A, Goldie SJ. HPV communication: Review of existing research and recommendations for patient education. CA Cancer J Clin. 2004;54:248–259.
DR SHARDA JAiN
SECREtARy gENERAl : Dgf
CHAiRpERSoN – WoW iNDiA
foUNDER CHAiRmAN –
DR ARUNA SAXENA
MD ( Obs & Gynae),KGMC Lucknow
Co-CooRDiNAtoR : CERviCAl
Dgf/ WoW iNDiA
Delhi Gynaecologist Forum
Initiative to spread information
to every woman & Girl in India
Please share with your friends
Human Papillomavirus (HPV)
HPV is a necessary cause of cervical cancer – 99.7%4
Cancer causing Types1,2,4
Non-cancer causing types1,2
• >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
Herold Zur Hausen
The Nobel Prize Winner, Medicine 2008
HPV is the necessary or the key cause of cervical
Cervical cancer does not and will not develop in
the absence of the persistent
presence of HPV DNA.
Cervical Cancer – Disease Burden in India
New Cervical Cancer Cases
Deaths due to Cervical cancer
World ~ 4,93,000
India ~ 74,000
World ~ 2,73,000
India - 27%
Rest of World - 73%
Rest of World - 73%
Rest of World - 73%
India ~27% of new
Cervical Cancer cases in world
India ~27% of deaths
due to Cervical Cancer in world
Bhatla N et al; Vaccine 2008; 26 2811-17
Cervical Cancer in India
> 200 women die every day
Cervical Cancer :
8 women die every hour
Every 7 minutes a women dies
This Cause needs to be taken up by multiple stake holders .
• 60% of girls with one
sexual partner will have
HPV infection within 3
years of beginning
• 80% of females get
infected with HPV by the
age of 50 years.
• Most infected individuals are unaware
they are infected and may unknowingly
spread the virus.
• Even Married couple with single partner
may have the disease
• Cancer cervix is preventable but yet
NOT prevented in our country.
• Continues to remain No
1 cancer in
Slow Growing Cancer:
Takes 10-20 yrs
Many opportunities for
•GOI – has
• Cervical cancer
screening in India among
rich and poor is uniformly
low, 6% and 4%
• WHO recommends
screening for all women ≥
30 yrs in India.1
1. Gakidou E, Nordhagen S, Obermeyer Z. Coverage of Cervical Cancer Screening in 57 Countries: Low Average Levels and Large Inequalities.
PLoS Medicine. June 2008; 5:863-868 Available at : www.plosmedicine.org
2. WHO. Comprehensive Cervical Cancer Control: A guide to essential practice. 2008: 86.
Available at: http://www.who.int/reproductive-health/publications/cervical_cancer_gep/text.pdf
which is highly effective and safe.
•New vista in cervical cancer
Efficacy of Vaccine
HPV induced lesions
Cervical Cancer &
Cervical Cancer &
Precancers (Grade 2/ 3)11
Precancers (Grade 2/ 3)
Vulvar/ Vaginal Precancers
Vulvar/ Vaginal Precancers
(Grade 1- 3)22
(Grade 1- 3)
1. The Future II Study Group. Lancet 2007; 369: 1861–68 2.Garland SM et al. New Engl J Med. 2007;356:1928–1943.
• Age for vaccination is 9 - 45 years.
• Three doses at 0, 2 and 6 months are recommended
with Quadrivalent vaccine
well tolerated with a favorable safety profile.
Consensus Recommendations on Immunization, Indian Academy of Pediatrics Committee On Immunization (IAPCOI). Indian Pediatrics 2008; (45)635-648
• Soreness & redness at local site is
• May be slight fever which is short lasting
relieved by simple medication
• No serious adverse reaction reported
Administration of Other
• Is safe at the same visit such as
Tdap, Hepatitis B or Meningococcal
• Vaccines should be administered using
a separate syringe at a different
• Australia has already vaccinated
85% of its target population
• Male Vaccination is now approved in
Aus, NZ, Philippines & recently
What Gynaecologists &
WOW India Volunteers can do ?
• High& middle Income Group: 1.Create
awareness about Vaccination &
2.Vaccinate Adoloscent Girls & women of 945 yrs of age. Encourage them to form a
chain by giving them incentives.
1. Arrange Fund for vaccination. Can initially target 1016 yrs old unmarried girls
2. See & Treat for married women of >30 yrs . Locate 34 gynaecologists in an area who can do monthly
camps at their clinics.
3. Frank cancer cases can be referred to
- Rotary Cancer Hospital AIIMS.
- Cancer Hospital in GTB
1. 27% of the world burden of Cervical Cancer is seen in India.
2. Cervical Cancer is caused by Human Papilloma Virus
3. Cervical Cancer is usually diagnosed in late stages in India.
4. Cancer Cervix Screening is recommended in between 21-65
yrs in low risk women
5.Cervical cancer vaccination: Recommended age : 9-45yrs in
Govt programme & GOI should take initiative without delay.
6.Vaccination efficacy 98-100%
7.No screening required for unmarried girls before
35 , Defence Enclave, Opp. Preet Vihar
Petrol Pump, Metro pillar no. 88, Vikas
Marg , Delhi – 110092