HUMAN PAPILLOMA VIRAL INFECTION 2010

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HUMAN PAPILLOMA VIRAL INFECTION 2010

  1. 1. HUMAN PAPILLOMA VIRUS Dr.Abdulrahman Lotfy Preventive Medicine Jahra Hospital
  2. 2. HPV-THE VIRUS HPV-THE INFECTIOUS DISEASE HPV-THE CARCINOGEN HPV/CANCER-THE VACCINE
  3. 3. HPV-THE VIRUS
  4. 4. <ul><li>MORPHOLOGY </li></ul><ul><li>Papilloma viruses are a group of well over 100 human and animal virus types, classified by their genomes. </li></ul><ul><li>Small, non-enveloped icosahedral particles (52-55nm) </li></ul><ul><li>72 capsomers (60 hexameric + 12 pentameric) </li></ul><ul><li>There are 2 capsid proteins, 1 major (encoded by the L1 gene) and 1 minor </li></ul>
  5. 5. HPV-THE INFECTIOUS DISEASE
  6. 6. Human Papillomavirus Types and Disease Association
  7. 7. Human Papilloma Virus <ul><li>Anogenital Disease: cervix, vulva, vagina, anus, penis </li></ul><ul><ul><li>Condylomata accuminatum </li></ul></ul><ul><ul><li>Squamous intraepithelial neoplasia </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><li>Head/Neck Disease: </li></ul><ul><ul><li>Mouth, tongue, tonsils </li></ul></ul><ul><ul><li>Sinuses </li></ul></ul><ul><ul><li>Oropharangeal </li></ul></ul><ul><ul><li>Respiratory mucosa (children; type 6, 11) </li></ul></ul><ul><ul><li>Cancer: usually HPV 16 </li></ul></ul><ul><li>Cofactors: Smoking, Alcohol </li></ul>
  8. 8. HPV-Associated Disease
  9. 9. HPV Types-Low & High Risk <ul><li>“ Low risk” types </li></ul><ul><ul><li>6, 11 (Genital warts) </li></ul></ul><ul><li>“ High risk” types (11) </li></ul><ul><ul><li>16, 18, 31, 33, 45, 56 </li></ul></ul>13 % 53%
  10. 10. Pathology and Pathogenesis <ul><li>Transmission occurs by close contact , </li></ul><ul><li>Viral particles are released from surface of paillomatous lesions </li></ul><ul><li>Causes infections at cutaneous and mucosal sites. </li></ul>
  11. 11. <ul><li>skin-to-skin contact with an infected individual </li></ul><ul><li>usually from vaginal, oral, or anal sexual contact, and can occur whether or not warts or other symptoms are present. </li></ul><ul><li>3. Vertical transmission. </li></ul><ul><li>4. nonsexual routes . </li></ul>Modes of Transmission
  12. 12. HPV Epidemiology <ul><li>Reservoir Human </li></ul><ul><li>Transmission Direct contact, </li></ul><ul><li>usually sexual </li></ul><ul><li>Communicability Presumed to be high </li></ul>
  13. 13. Epidemiology <ul><li>Globally more than 660 million people are infected with Genital human papillomas infections. </li></ul><ul><li>Most common infection of the Genital tract. </li></ul><ul><li>2-6 million new infections occur in USA. </li></ul><ul><li>Most common in youth < 25 years </li></ul><ul><li>HPV infections are accepted as the cause of anogenital cancers. Majority are linked to HPV type 16 </li></ul><ul><li>HPV type 18 is found in Cervical carcinomas </li></ul><ul><li>HPV 16 and 18 are identified in > 70 % of cervical carcinomas </li></ul>
  14. 14. Epidemiology –cont. <ul><li>Men who have sex with men develop Rectal cancers </li></ul><ul><li>Oropharyngeal Cancers - subset of Head and Neck are associated with sqaumous cell cancer type associated with HPV 16 </li></ul><ul><li>Role of men as carriers –Most men with HPV are subclinical and donot result in HPV associated disease </li></ul>
  15. 15. Infections present with <ul><li>Skin warts </li></ul><ul><li>Plantar warts </li></ul><ul><li>Flat warts </li></ul><ul><li>Genital – condylomas </li></ul><ul><li>Laryngeial paillomas </li></ul>
  16. 16. Clinical Manifestation of HPV <ul><li>The incubation period for genital warts is usually between three and six months, but it may last for years after exposure. </li></ul><ul><li>2. small bumps that appear in the genital area or anus. They may be single or clusters and have a cauliflower-like appearance as they grow larger. </li></ul><ul><li>It can appear in mouth or throat of a person who has had sexual contact with an infected person. </li></ul>
  17. 17. Women: Genital warts usually start to appear appear on the vulva, in the vagina, on the cervix, or in the anal area
  18. 18. In men, they appear on the foreskin, head or shaft of the penis, and in the anal area, urethra, and scrotum
  19. 19. Rare skin warts <ul><li>Tree Man </li></ul>
  20. 20. HPV – Sexual Transmission <ul><li>HPV genital infections are sexually transmitted </li></ul><ul><li>Represent the most common sexually transmitted disease in United States </li></ul>
  21. 21. Symptoms of HPV <ul><li>lesions of the skin epithelium or the mucosal linings of the anogenital area, oral cavity, and respiratory tract. </li></ul><ul><li>2. The most common (and benign) symptomatic presentation of an HPV infection is condylomata acuminata (genital warts). </li></ul><ul><li>3. Other visible HPV infections are the plantar warts and the common warts. </li></ul><ul><li>4. Asymptomatic/sub clinical HPV infection. </li></ul>Pap Test Hybrid Capture II HPV
  22. 22. SUPERFICIAL (Flat) WARTS
  23. 23. PLANTAR WARTS
  24. 24. GENITAL CONDYLOMAS
  25. 25. INTERNAL WARTS Also includes Laryngeal warts (not shown here)
  26. 26. COLORECTAL CONDYLOMAS
  27. 27. Pap Smear – Cervical Cancer <ul><li>A Pap smear test may indicate the possible presence of cervical HPV infection. </li></ul><ul><li>A Pap smear is a microscopic examination of cells scraped from the uterine cervix in order to detect cervical cancer. </li></ul><ul><li>Abnormal Pap smear results are associated with HPV infection. Women with abnormal Pap smears should be examined further to detect and treat cervical problems. </li></ul>
  28. 28. TREATMENT: Low Grade Lesions <ul><li>Treatment is not usually necessary (infections regress quickly) </li></ul><ul><li>2. Cryotherapy </li></ul><ul><li>3. Laser Ablation Therapy </li></ul><ul><li>4. LEEP (loop electrical excision behavior) </li></ul>
  29. 29. TREATMENT: High Grade Lesions <ul><li>Necessary to avoid progression to malignancy </li></ul><ul><li>2. Cryotherapy </li></ul><ul><li>3. Laser Ablation Therapy </li></ul><ul><li>4. LEEP (loop electrical excision behavior) </li></ul>
  30. 30. TREATMENT: Genital Warts <ul><li>TOPICAL CHEMODESTRUCTIVE AGENTS </li></ul><ul><li>Tri-(or Bi) chloracetic acid (TCA or BCA) </li></ul><ul><li>Podophyllum: Is an extract of the May apple plant </li></ul><ul><li>2. Self Treatments (topical) </li></ul><ul><li>Condylox[R]: purified podophyllotoxin (podophilox). </li></ul><ul><li>Imiquimod: an immune response modifier </li></ul><ul><li>3. Adjunctive Treatments (no longer extensively used due to side effects (i.e. efudex, interferon) </li></ul>
  31. 31. HPV-THE CARCINOGEN
  32. 32. 93% of all cervical neoplasia cases test are positive for HPV making it the leading the third leading killer among women Cancer: Predominant types: Co-factors: Skin carcinomas HPV-5, 8 U.V., genetic? Lower genital tract cancers HPV-16, 18, 31, 33 ??? Malignant transformation of respiratory papillomas HPV-6, 11 X-rays
  33. 33. Cervical – HPV infection <ul><li>Cervical cancer is second most frequent cancer in women world wide </li></ul><ul><li>5,00,000 cases present with cervical cancer </li></ul><ul><li>Major leading cause of deaths related to malignancy in the Devloping world </li></ul><ul><li>Several cases associated with HPV infections . </li></ul>
  34. 34. HPV infections predisposes to Cervical Cancer
  35. 35. CANCER CERVIX
  36. 36. HPV/Cancer-THE VACCINE
  37. 37. Human Papillomavirus Vaccine <ul><li>HPV L1 major capsid protein of the virus is antigen used for immunization </li></ul><ul><li>L1 protein expressed in yeast cells using recombinant technology </li></ul><ul><li>L1 proteins self-assemble into virus-like particles (VLP) </li></ul><ul><li>VLPs are noninfectious and nononcogenic </li></ul>
  38. 38. Risk with different types of viruses 30, 31, 33, 35, 39, 45, 51 and 53 6, 11, 40, 42 – 44, 54, 61,70, 72 and 81
  39. 39. HPV Vaccine Efficacy* *Among 16-26 year old females. CIN – cervical intraepithelial neoplasia; AIS – adenocarcinoma in situ
  40. 40. HPV Vaccine Efficacy <ul><li>High efficacy among females without evidence of infection with vaccine HPV types </li></ul><ul><li>No evidence of efficacy against disease caused by vaccine types or which participants were infected at the time of vaccination </li></ul><ul><li>Prior infection with one HPV type did not diminish efficacy of the vaccine against other vaccine HPV types </li></ul>
  41. 41. Routine HPV Vaccination Recommendations <ul><li>ACIP recommends routine vaccination of females 11 or 12 years of age </li></ul><ul><li>The vaccination series can be started as young as 9 years of age at the clinician’s discretion </li></ul><ul><li>“ Catch-up” vaccination recommended for females 13 through 26 years of age </li></ul>MMWR 2007;56(RR-2):1-24
  42. 42. HPV Vaccination Schedule <ul><li>Routine schedule is 0, 2, 6 months </li></ul><ul><li>Third dose should follow the first dose by at least 24 weeks </li></ul><ul><li>An accelerated schedule using minimum intervals is not recommended </li></ul><ul><li>Series does not need to be restarted if the schedule is interrupted </li></ul>
  43. 43. Efficacy of Gardasil HPV induced lesions Cervical Cancer & Precancers (Grade 2/ 3) 1 Vulvar/ Vaginal Precancers (Grade 1- 3) 2 Genital Warts 2 Protection by QHPV 98% 100% 99% 1. The Future II Study Group. Lancet 2007; 369: 1861–68 2.Garland SM et al. New Engl J Med. 2007;356:1928–1943.
  44. 44. HPV Vaccine Special Situations * <ul><li>Equivocal or abnormal Pap test </li></ul><ul><li>Positive HPV DNA test </li></ul><ul><li>Genital warts </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Breastfeeding </li></ul>* Vaccine can be administered
  45. 45. HPV Vaccine Adverse Reactions <ul><li>Local reactions 84% </li></ul><ul><li>(pain, swelling) </li></ul><ul><li>Fever 10%* </li></ul><ul><li>No serious adverse reactions reported </li></ul>*similar to reports in placebo recipients (9%)
  46. 46. Syncope Following Vaccination <ul><li>An increase in the number of reports of syncope has been detected by the Vaccine Adverse Event Reporting System (VAERS) </li></ul><ul><li>11-18 year old females have contributed most of the increase </li></ul><ul><li>Serious injuries have resulted </li></ul><ul><li>Providers should strongly consider observing patients for 15 minutes after they are vaccinated </li></ul>
  47. 47. HPV Vaccine Contraindications and Precautions <ul><li>Contraindication </li></ul><ul><ul><li>Severe allergic reaction to a vaccine component or following a prior dose </li></ul></ul><ul><li>Precaution </li></ul><ul><ul><li>Moderate or severe acute illnesses (defer until symptoms improve) </li></ul></ul>
  48. 48. HPV Vaccination During Pregnancy <ul><li>Initiation of the vaccine series should be delayed until after completion of pregnancy </li></ul><ul><li>If a woman is found to be pregnant after initiating the vaccination series, remaining doses should be delayed until after the pregnancy   </li></ul><ul><li>If a vaccine dose has been administered during pregnancy, there is no indication for intervention </li></ul>MMWR 2007;56(RR-2):1-24
  49. 49. HPV Vaccine Storage and Handling <ul><li>Store at 36°F-46°F (2°C-8°C) </li></ul><ul><li>Protect from light </li></ul><ul><li>Do not expose to freezing temperature </li></ul><ul><li>Remove from refrigeration immediately before administration </li></ul>
  50. 50. <ul><li>THANK YOU </li></ul>

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