post partum vaccination dr. jyoti agarwal, dr. sharda jain

POST-PARTUM PERIOD: an excellent OPPORTUNITY FOR HPV VACCINATION

Dr. Sharda Jain

Director :-

Chairman PCH OBST/ Gynae Dpt.

Presented at Opinion leaders meet on HPV vaccine at Delhi 4/8/2013

DR. Jyoti Agarwal

Human Suffering

Due To

Cervical Cancer in India

Is depressing •women who die due to Cervical Cancer in the world is an Indian

1 out of 4

Walboomers jM et al. j pathol, 1999: 189:12-9

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.

We Know The Cause !!

80+%

~40%

~100%

60-90%

~100%

Percentages represent cases atrributable to HPV infection

Cervical Cancer1,3

Vulvar Cancer1

Vaginal Cancer1

Anal Cancer1-3

Genital Warts1,3

12-70%Head &

Neck Cancer3

45%Penile

Cancer3

We also Know the STRATEGY

This cancer is 100% Preventable !!

Regular screening

vaccination

offers best possible protection against Cervical Cancer

How

To

Handle

CERVICAL

CancerIn India

VaccinationFamous Phase III trials HPV vaccines

• FUTURE – Females Unites to unilaterally reduce Endo/ Ectocervical Disease

• PATRICIA – Papilloma Trial Against Cancer In Young Adults

Universal Vaccination

GOI – has no money for universal vaccination

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

Second Fact

The efficacy of the vaccine against cervical

disease is reduced among women who

are HPV seropositive at the time of

vaccine administration

• Screening/ HPV test is not required

prior to vaccination

• Screen positive women may be

vaccinated after counseling

FOGSI Recommendations:Vaccination & Screening

www.fogsi.org/hpv vaccine

Catch up Vaccination

Is

Thus a

Big Challenge !!

Herold Zur HausenThe 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.

HPV 16

HPV 18

HPV 6

HPV 11

Cancer causing Types1,2,4 Non-cancer causing types1,2

>75% of Cervical Cancer5,6

>50% of Vaginal & Vulvar Cancer590% of Anogenital warts5

HPV is a necessary cause of cervical cancer – 99.7%4

HPV

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

Human Papillomavirus (HPV)

http://www.who.int/hpvcentre6

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?

?

*Knee jerk reaction*

Should we err on side of caution or hope ?

Medical Knowledge is always

Incomplete and ambiguous

Promise of - New Life NEW

DIRECTION

GOI - Focus on adolescents vaccination - See & treat mission

Gynaecologists & Individuals - Focus on catch up vaccination - screening

Postpartum HPV vaccination

POST-PARTUM PERIOD: AN OPPORTUNITY FOR HPV

VACCINATION

• Cerverix - Not recommended

during pregnancy

• Gardasil - Can be given in

lactation period

FOGSI Recommendations:Pregnancy and Lactation


23

• 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 inda 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 yne c o l 2 0 1 2 ; 1 2 0 : 7 7 1 – 8 2

Postpartum HPV Vaccination

Two Facts

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. Wright, Govindappagari, Pawar et al, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, Obstet Gynecol 2012;120:771–82

OPPORTUNITY FOR CATCH-UP HPV VACCINATION IN YOUNG WOMEN AFTER

FIRST DELIVERY

Rama et al (2006-07 ) Brazil

25

Primiparous 15 – 24 years

Results26

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

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.



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



ACCEPTANCE AND COMPLIANCE WITH

POSTPARTUM HUMAN PAPILLOMAVIRUS

VACCINATION

Wright et al (2012)

29

Postpartum women 18 – 26 years (N150)3 visits at delivery 1st dose6 weeks second dose6 month 3 dose Quadrivalent HPV Vaccine

Obstet Gynecol 2012;120:771–82

Materials & Methods30

• 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

Results31

• 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.

Wrig ht, G o vinda p p a g a ri, Pa war e t a l, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bs te t G yne c o l 2 0 1 2 ; 1 2 0 : 7 7 1 – 8 2Wright et al (2012) Obstet Gynecol 2012;120:771–82

Results32 • 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

Wrig ht, G o vinda p p a g a ri, Pa war e t a l, Acceptance and Compliance With Postpartum Human Papillomavirus Vaccination, O bs te t G yne c o l 2 0 1 2 ; 1 2 0 : 7 7 1 – 8 2Wright et al (2012) Obstet Gynecol 2012;120:771–82

POST-PARTUM PERIOD : is excellent OPPORTUNITY FOR

HPV VACCINATION

Experience Of last two years (2011-13)

(N – over 200)

99% compliance

• Happy

• Convenient

• Recommended to her friends / Relative

• No therapeutic role in

treating pre existing HPV

infection or CIN lesion

• No booster required - as of

now

FOGSI Recommendations:Need for boosters & Therapeutic role


Be true to your highest conviction !!

Thank You

post partum vaccination dr. jyoti agarwal, dr. sharda jain

Health & Medicine