POST PARTUM PERIOD: AN OPPURTUNITY FOR HPV VACCINATION

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.

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.

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.

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)

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 .

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).

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

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

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

Rama and colleagues

STUDY POPULATION JUNE 2006 TO FEB 2007

primiparous age 15 to 24 yrs.

residents of sao paulo > 6 months.

delivered beyond 32 wks of gestation.

EXCLUSION CRITERIA

Non residents of brazil.

Immunodeficiency disorders.

Unable/ unwilling to give consent.

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

EPIDEMIOLOGICAL DATA ABOUTDERMOGRAPHIC CHARACTERISTICS.

SEXUAL BEHAVIOUR .

REPRODUCTIVE HISTORY.

CONTRACEPTIVE USE.

SMOKING HABITS.

CLINICAL EXAMINATION

PELVIC EXAMINATION.

PAP SMEAR USING LIQUID BASED CYTOLOGY SYSTEM.

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.

Results17

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

PAP FINDINGS4.1% HAD ABNORMAL RESULTS.

ASCUS ( abnormal squamous cells of undetermined significance)

LSIL( low grade squamous intraepithelial lesions)

HSIL( high grade squamous intraepithelial lesions)

HIGH RISK HPV WAS FOUND IN

ALL LSIL

ALL HSIL

HALF OF ASCUS

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.

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

Results22

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

IMPACT OF EDUCATION

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

SMOKINGFORMER SMOKERS -60%.

CURRENT SMOKERS-88%.

EVER SMOKED MORE LIKELY TO BE INFECTED.

SMOKING SEEMS TO ALTER THE IMMUNE RESPONSE OF CERVICAL TISSUES.

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 < 25 yrs as compared to non pregnant.

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

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.

THIS STUDY SUPPORTS:

This population would derive benefit from catch up vaccination.

Target group for effective primary and secondary preventive cervical cancer programmes.

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.

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.

ACCEPTANCE AND COMPLIANCE WITH POSTPARTUM HUMAN PAPILLOMA VIRUS VACINATION

Wright and colleagues

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).

INCLUSION CRITERIAWoman in postpartum period after delivery at

32 – 44 wks.

If willing answered questionnaire regarding knowledge of HPV and its related disease.

FIRST DOSE OF HPV ADMINISTERED BEFORE DISCHARGE

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.

RESULTSTotal 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.

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.

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.

DISCUSSIONPostpartum administration of HPV

• FEASIBLE.

• ASSOCIATED WITH HIGH DEGREE OF SATISFACTION.

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.

DISCUSSION (cont)....Completion of series remains a major

challenge.

Antenatal counselling by primary obstetrician may bolster enrolment and completion of series.

SUMMARYYoung 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.

THANK YOU FOR KIND ATTENTION