POST PARTUM PERIOD: AN OPPURTUNITY FOR HPV VACCINATION

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POST PARTUM PERIOD AN OPPURTUNITY FOR HPV
VACCINATION
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• Genital infection by HPV is a necessary factor in
  development of cancer of cervix.
• Worldwide approximately 80 of around 500,000
  registered cases of ca . Cervix were from
  developing countries.

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• High risk genotypes are 16 and 18.
• Vaccines have been developed.
• Excellent safety, immunogenicity and efficacy
  profile.
• Ideally HPV vaccination should be taken before
  sexual debut.

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• Adolescent girls and young women have little
  interaction with healthcare system.
• This is at higher risk among young female
  population.
• Opportunities for catch up vaccination are
  valuable to improve coverage.

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Development of strategies for prevention of HPV
is major concern

• Vaccination rates for target group is very low.
• School vaccination / free vaccination adopted by
  some countries.
• 80 success in former(UK AND AUSTRALIA)
• 58 to 60 in latter (ITALY AND DENMARK)

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• Healthcare provided at first delivery is one
  such valuable oppurtunity.
• Early age at first delivery is known risk factor
  for carcinoma cervix.
• HPV vaccination is very safe for lactating women
  .

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• Success of vaccination depends upon prevalence of
  HPV types 16 and 18 in target group of postnatal
  women.
• HPV infection rates were 10.1 to 37.2 in
  pregnant women (all ages and parity).

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IMPORTANT STUDY BY RAMA AND COLLEAGUES

• Prevalence of cervical type specific HPV DNA.
• Risk factor associated with HPV infection .
• Primparous low income women .
• Research
  report J.Epidemiol 2010

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WRIGHT AND COLLEAGUES

• Developed a targeted intervention of HPV
  vaccination during post partum period .
• Women are actively engaged with healthcare
  system .
• They tested the acceptance and compliance of
  women at three points during the postpartum
  period.
• ACOG
  Obstetric Gynecol Oct 2012

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OPPURTUNITY FOR CATCH UP HPV VACCINATION IN YOUNG
WOMEN AFTER FIRST DELIVERY Rama
and colleagues


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STUDY POPULATION JUNE 2006 TO FEB 2007

• primiparous age 15 to 24 yrs.
• residents of sao paulo gt 6 months.
• delivered beyond 32 wks of gestation.

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EXCLUSION CRITERIA

• Non residents of brazil.
• Immunodeficiency disorders.
• Unable/ unwilling to give consent.

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• Women were recruited to take part in the study
  during the post delivery follow up period.

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EPIDEMIOLOGICAL DATA ABOUT

• DERMOGRAPHIC CHARACTERISTICS.
• SEXUAL BEHAVIOUR .
• REPRODUCTIVE HISTORY.
• CONTRACEPTIVE USE.
• SMOKING HABITS.

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CLINICAL EXAMINATION

• PELVIC EXAMINATION.
• PAP SMEAR USING LIQUID BASED CYTOLOGY SYSTEM.

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MATERIAL AND METHODS

• STATISTICAL ANALYSIS
• detection rates of HPV infection
  using PCR were described as Percentages with 95
  CI.
• To estimate association of HPV infection with
  selected risk factors , prevalence ratios and
  95 CI were calculated , with HPV infection as
  the dependent variable and various exposure
  factors as independent variables.

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Results
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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
201064610e615
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PAP FINDINGS

• 4.1 HAD ABNORMAL RESULTS.
• ASCUS ( abnormal squamous cells of
  undetermined significance)
• LSIL( low grade squamous intraepithelial
  lesions)
• HSIL( high grade squamous intraepithelial
  lesions)

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HIGH RISK HPV WAS FOUND IN

• ALL LSIL
• ALL HSIL
• HALF OF ASCUS

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• OVERALL HPV WAS FOUND IN 58.5 WOMEN.
• HIGH RISK AT LEAST ONE HIGH RISK TYPE WAS
  FOUND IN 44.2 OF THESE YOUNG PRIMI PARAS.

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THESE YOUNG PRIMIPAROUS WOMEN HAD HIGH
PREVALENCE OF HPV SUGGESTING THAT THIS
IS A HIGH RISK GROUP FOR CARCINOMA
CERVIX.
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Results
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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
201064610e615
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IMPACT OF EDUCATION

• ELEVEN OR MORE YEARS OF SCHOOLING HAD 50 LOWER
  PREVALENCE RATES.

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SMOKING

• FORMER SMOKERS -60.
• CURRENT SMOKERS-88.
• EVER SMOKED MORE LIKELY TO BE INFECTED.
• SMOKING SEEMS TO ALTER THE IMMUNE RESPONSE OF
  CERVICAL TISSUES.

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DISCUSSION

• The 58.5 incidence found in young primiparous
  patients in this study was higher than that
  found in earlier population based surveys,
  varying from 7.0 to 33.8.
• 17.3 and 13.3 of the participants were positive
  for the two oncogenic HPV types 16 and 18 ,which
  are also included in the quadrivalent vaccine.
• Hence majority of this group could draw full
  benefit from catch up HPV vaccination and
  protection agajnst cervical cancer.
• Higher incidence of high risk HPV type in
  pregnant women lt 25 yrs as compared to non
  pregnant.

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IMPORTANT STUDIES
KAMPALA UGANDA concurrent pregnancy
associated with 82.8 HPV infection rates as
compared to 73 in non pregnant women. MEXICO
AND BRAZIL pregnancy associated with
higher prevalence (49.5 44.2 ) of at least
one high risk HPV type I
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• Physiological processes established during
  pregnancy alter host immune response and hormonal
  status.
• Pregnant women become more vulnerable to HPV
  infection as measured in neonatal periods.

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THIS STUDY SUPPORTS

• This population would derive benefit from catch
  up vaccination.
• Target group for effective primary and secondary
  preventive cervical cancer programmes.

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• Advisory Committee on Immunization Practices of
  Centers for Disease Control in USA recommends.
• Catch up vaccination of unvaccinated
  females 13 to 26 yrs .
• All who have not completed full immunization
  series.

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• Postpartum period is a suitable oppurtunity to
  vaccinate young women utilising in place, health
  services like post partum check up clinics,
  family planning clinics and infant immunisation
  clinics.

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ACCEPTANCE AND COMPLIANCE WITH POSTPARTUM HUMAN
PAPILLOMA VIRUS VACINATION Wright and
colleagues
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MATERIALS AND METHODS

• Estimation of acceptibility of HPV vaccination in
  postpartum women 18-26 yrs.
• During hospitilisation after delivery (1 st
  dose).
• At 6 week postpartum visit (2 nd dose)(42-70
  days).
• At subsequent visit for vaccination (3 rd dose)
  (160 days from 2 nd dose).

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INCLUSION CRITERIA

• Woman in postpartum period after delivery at 32
  44 wks.
• If willing answered questionnaire regarding
  knowledge of HPV and its related disease.

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• FIRST DOSE OF HPV ADMINISTERED BEFORE DISCHARGE

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MATERIALS AND METHODS
PRIMARY OBJECTIVE To estimate
compliance in receiving three doses of vaccine
when the vaccine was administered in the
postpartum setting . SECONDARY OBJECTIVE
To examine the influence of knowledge
decisional conflict on compliance with the
vaccine series and to estimate patient
satisfaction with postpartum vaccination.
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RESULTS

• Total of 150 women were enrolled in the study
• SURVEY RESULTS
• 80 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.
• 64 knew that it caused Carcinoma Cervix.

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RESULTS

• 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.

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• AMONG THOSE VACCINATED
• 99.3 were happy they participated in the study
  and
• 97.9 would have recommended the vaccine to a
  friend

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• Despite the acceptability of this strategy only
  30.7 of enrolled patients completed the three
  vaccine series.

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DISCUSSION

• Postpartum administration of HPV
• FEASIBLE.
• ASSOCIATED WITH HIGH DEGREE OF SATISFACTION.

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DISCUSSION (cont)....

• Pregnant women are actively engaged with the
  health care system .
• Administration of HPV during post partum
  hospitalization and at 6 weeks visit would be
  more effective to overcome the limited access to
  healthcare system.
• Strategy well accepted by women as they did not
  have to make seperate trips to the hospital.

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DISCUSSION (cont)....

• Completion of series remains a major challenge.
• Antenatal counselling by primary obstetrician may
  bolster enrolment and completion of series.

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SUMMARY

• Young primi parous women had high prevalence of
  cervical HPV infection.
• High rates of high risk HPV in pregnant
  postpartum women.
• Engagement with healthcare system during
  pregnancy creates a good target group to initiate
  vaccination.
• Patient satisfaction with vaccination in this
  group is high resulting in higher compliance.
• Completion of series still remains a major
  challenge.

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THANK YOU FOR KIND ATTENTION