This document summarizes a panel discussion on HPV vaccination in India. Some key points: - Cervical cancer is a major problem in India, with over 122,000 new cases and 67,000 deaths annually. - HPV is the primary cause of cervical cancer. Vaccination induces high antibody levels to protect against HPV types 16 and 18, which cause 70% of cervical cancers. - The best age for vaccination is 11-12 years, before sexual debut. Catch-up vaccination is recommended through age 26. - Common side effects of HPV vaccination are mild and temporary. Rare severe allergic reactions may occur. - Vaccination is recommended even for sexually active women and women in monogamous relationships to

1. HPV VACCINATION-
UPDATE AND PRACTICAL
ASPECTS

2. PANEL DISCUSSION
MODERATOR: DR. RUPAM ARORA / Dr. Sharda Jain
PANELISTS:
• DR. ARUNA SAXENA
• DR. DEEPTI NABH
• DR. ILA GUPTA
• DR. JYOTI AGARWAL
• DR. RAJ BOKADIA
• DR. RENU CHAWLA

3. IS CERVICAL CANCER COMMON?

4. DISEASE BURDEN OF CERVICAL
CANCER
India ~1,22,844
Total world ~ 5,27,624
India ~23% of new
Cervical Cancer cases in world
Rest of World - 77%
Incidence
India ~23%
India ~ 67,477
Total world ~ 2,65,653
India ~25% of deaths
due to Cervical Cancer in world
Mortality
India ~25%
Rest of World - 75%
2. Bruni L, Barrionuevo-Rosas L, Serrano B, Brotons M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in India. Summary Report
2014-01-31. [Accessed on 11th Feb 14]

5. 67,477
Deaths
Annually
Approx. 185 women die every day
Every 8 minutes a women dies
Approx. 8 women die every hour
CERVICAL CANCER- THE INDIAN
CONTEXT
Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related
Diseases in India. Summary Report 2015-03- 20. [Accessed on 1st July 2015]

6. An Airbus-320, full of women crashing every day in India
Deaths Due to CaCx- Just Think!

7. DELHI-110001 • Times of India
• New Delhi
• March 1st, 2016
• Delhi is going to be the first
state in the country to
introduce preventive
vaccination for Cervical Cancer

8. HPV 16
HPV 18
HPV 6
HPV 11
Cancer causing Types
High risk group-16,18,
31,33,45,52,58
90% of Anogenital warts5
HPV is a necessary cause of cervical cancer – 99.7%4
HPV
Need for multivalent HPV vaccine for broader HPV protection

9. WHAT ARE THE OTHER CANCERS
LINKED TO HPV INFECTION?

10. Genital
Warts ~100%
70%
~100%
43%
88%
Cervical
Cancer
Vaginal
Cancer
Vulvar
Cancer
Anal
Cancer
13-56%
Orophary
ngeal
Cancer
50%
Penile
Cancer
HPV
HPV Causes More Than Cervical Cancer

11. WHY VACCINATE?

12. • Screening rates in India very low
• Natural HPV Infection induces a weak immune response
• Role of vaccine:
• Induces high antibody levels at the basal epithelium of cervix
• Induces long lasting protection

13. WHAT IS THE BEST AGE TO
VACCINATE?

14. ACIP GUIDELINES
• 11 -12 years, before onset of sexual
activity
• Vaccination recommended through age
26 for females and through age 21 for
males not previously vaccinated
• Vaccination recommended for men who
have sex with men and
immunocompromised men (including
persons HIV infected) through age 26
FOGSI GUIDELINES
• As early as the age of 9 years, before
commencement of sexual activity
• Catch up vaccination is permitted up to
45 years in case of incomplete
vaccination

15. ACIP & AAP- 2011
• Consider giving HPV4 to MALES age 9 through 26 years to reduce
their likelihood of acquiring genital warts
IAP & FOGSI
• HPV vaccine should be given to females from 9 - 45 years of age for
prevention of cervical cancer

16. WHAT IS POST PARTUM CATCH-UP
VACCINATION?

17. • Vaccination rates for target group are very low
• To improve coverage among at-risk young female population, catch-up
vaccination are valuable
• Potential opportunity for HPV catch-up vaccination is offered by
healthcare provided at first delivery
• Early age at first delivery has been identified as risk factor for cervical
cancer development

18. WHAT ARE THE TYPES OF HPV
VACCINE?

19. CERVARIXTM GARDASILTM GARDASIL 9TM
Bivalent vaccine Quadrivalent vaccine 9 valent vaccine
HPV 16, 18 HPV 6, 11 & 16, 18 HPV 6, 11, 16, 18, 31,
33, 45, 52, 58
FDA approved in 2010 FDA approved in 2006 FDA approved in 2014
Females only Females and Males Females and Males

20. ARE GARDASIL AND CERVARIX
INTERCHANGEABLE?

21. • No evidence that HPV bivalent and quadrivalent vaccines are
interchangeable
• If an individual has started course of one vaccine then vaccination
series should be completed with that vaccine

22. HOW MANY DOSES ARE NEEDED AND
ON WHAT SCHEDULE?

23. • Vaccine is given as an injection in the deltoid muscle of the arm
• Since 2006, HPV vaccines have been recommended in 3-dose series
given over six months (0, 1-2 and 6 months)
PRIM
E
PRIME BOOSTE
R
0 1 -2 6

24. UPDATED DOSING SCHEDULE- ACIS
2016
• Females <15 years at time of first dose:
• 2-dose schedule (0, 6 months) is recommended
• If interval between doses is shorter than 5 months, then third dose
should be given at least 6 months after first dose
• Females ≥15 years at time of first dose:
• 3-dose schedule (0, 1-2, 6 months) is recommended
• 3 doses are still recommended for people with certain
immunocompromising conditions aged 9 - 26 years

25. DO WE NEED SCREENING BEFORE
GETTING VACCINATED?

26. • Screen positive women should be vaccinated after counseling
• Screening / HPV test is NOT required prior to vaccination
(FOGSI recommendation)

27. DO WE NEED SCREENING AFTER
GETTING VACCINATED?

28. • Regular cervical cancer screening recommended
• Vaccine does not provide protection against all types of HPV that cause
cervical cancer
• Full benefits of vaccine not conferred if vaccine series is not completed
• Women may not receive the full benefits of the vaccine if they were infected
with HPV before receiving the vaccine

29. WHAT ARE THE ADVERSE EFFECTS
OF HPV VACCINE?

30. Common side effects of HPV vaccine include:
• Pain, redness, or swelling in the arm where the shot was given
• Fever
• Headache or feeling tired
• Nausea
• Muscle or joint pain

31. • Increase rate of syncopal event
• Rare occasions, severe (anaphylactic) allergic reactions may occur
after vaccination
• Gullain-Barre Syndrome: 3/million (other vaccines 15.7/million)
• Deaths: 20 with qHPV alone – No clustering
(Slade et al., JAMA, 2009)

32. WHAT PRECAUTIONS MUST BE
TAKEN WHILE ADMINISTERING THE
VACCINE?

33. • Fainting has been reported among adolescents who receive HPV
vaccine
• Recommended that patient sits during administration and remains
seated for 15–20 minutes after receiving vaccine

34. WHAT IS THE EFFICACY AND
DURATION OF HPV VACCINE
PROTECTION?

35. • Prevent nearly 100 percent of precancerous cervical cell changes
caused by types of HPV included in vaccine for more than 8 years
after vaccination
• Among males:
• Efficacy for prevention of genital warts was 89%
• Efficacy for the prevention of precancerous lesions of the anus was
78%

36. WHAT IF A PERSON DOES NOT GET
ALL OF THE RECOMMENDED THREE
DOSES?

37. • Protection from incomplete schedule of HPV vaccine- not known
• If gap in schedule is longer than recommended time, then continue
from where it was left off
• No need to restart series

38. WHAT ARE THE CONTRAINDICATIONS
OF HPV VACCINE?

39. • Sensitive to yeast or to any of vaccine components
• Acute severe febrile illness; defer until recovery
• Coagulation defects (use 23-gauge needle, apply pressure for 1-2
minutes after injection)
• No data on use in individuals with impaired immune responsiveness

40. CAN HPV VACCINE BE ADMINISTERED
DURING PREGNANCY AND
LACTATION?

41. • Not recommended for use in pregnancy
• If patient becomes pregnant- delay remaining doses till delivery
• If vaccinated during pregnancy- no intervention (MTP) needed
• Lactating women can receive HPV vaccine and still continue
breastfeeding as it not live viral DNA vaccine
(FOGSI recommendation)

42. IS THERE ANY BENEFIT IN
VACCINATING SEXUALLY ACTIVE
WOMEN?

43. • HPV vaccination is likely to benefit sexually active women due to:
• Continuous risk of acquiring new HPV infections
• Developing cervical intraepithelial neoplasia (CIN) and cervical
cancer
• Vaccination will not alter progression of pre-existing HPV infection or
development of consequences of infection

44. CAN VACCINE BE GIVEN TO A GIRL WHO
HAS PREVIOUSLY BEEN DIAGNOSED
WITH HPV INFECTION?

45. • Yes. The vaccine can be given to a girl who has previously acquired
a HPV infection

46. WHY DO WE NEED TO VACCINATE WOMEN
IN MONOGAMOUS RELATIONSHIPS?

47. • Cumulative risk of cervical HPV infection in women with only one
sexual partner is 46% (3 years after first sexual encounter)

48. CASE STUDY 1
• 45 year old lady, divorced, currently sexually inactive presents to
your clinic for health check.
• She plans to remarry and asks about HPV vaccination
• What would you recommend to her?

49. CASE STUDY 2
• 26 years old woman presents to your clinic at 10 weeks gestation for
prenatal health check. Pap smear reveals ASCUS. She has received
the first two doses of an HPV vaccine and asks if she should receive
the third dose.
• What would you tell her?

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