1. HPV: Cervical CancerHPV: Cervical Cancer
and the Vaccineand the Vaccine
Abhijit Chaudhury.Abhijit Chaudhury.

2. HistoryHistory
► Warts were known to the ancient GreeksWarts were known to the ancient Greeks
and Romans.and Romans.
► Their infectious nature was also known.Their infectious nature was also known.
► 1894-1924: Ciufo, Variot and others1894-1924: Ciufo, Variot and others
showed that genital and skin warts can beshowed that genital and skin warts can be
transmitted between individuals by atransmitted between individuals by a
filterable infectious agentfilterable infectious agent..

3. HistoryHistory
► Richard Shope(1933):Richard Shope(1933):
First identified theFirst identified the
animal papillomavirusanimal papillomavirus
and showed itsand showed its
transmissible naturetransmissible nature
using the cottontailusing the cottontail
rabbit.rabbit.
► 1950s,60s: Physico-1950s,60s: Physico-
chemical analysis andchemical analysis and
replication studies.replication studies.

4. HistoryHistory
► 1842: Rigoni-Stern reports that prostitutes1842: Rigoni-Stern reports that prostitutes
have much higher incidence of cervicalhave much higher incidence of cervical
cancer than nunscancer than nuns
► 1935 (Rous) papillomas can progress to1935 (Rous) papillomas can progress to
carcinoma.carcinoma.
► 1951: George Otto Gey establishes in vitro1951: George Otto Gey establishes in vitro
culture of HeLa (Henrietta Lacks) cellsculture of HeLa (Henrietta Lacks) cells
derived from a lethal cervical cancerderived from a lethal cervical cancer

5. HistoryHistory
► Mid 1970s: Meisels and FortinMid 1970s: Meisels and Fortin
recognized on morphologicalrecognized on morphological
grounds an associationgrounds an association
between HPV infection ofbetween HPV infection of
cervix and CIN.cervix and CIN.
••1983: Harald zur Hausen1983: Harald zur Hausen
discovers new HPV typesdiscovers new HPV types
(types 16 and 18) in HeLa(types 16 and 18) in HeLa
cells and other cervical cancercells and other cervical cancer
cells.cells.
••2008: Harald zur Hausen wins2008: Harald zur Hausen wins
Nobel Prize for his workNobel Prize for his work
establishing a causal linkestablishing a causal link
between HPVs and cervicalbetween HPVs and cervical
cancer.cancer.

6. HPV----- BiologyHPV----- Biology
►Originally classified together withOriginally classified together with
polyomavirus in the familypolyomavirus in the family Papovaviridae.Papovaviridae.
► Assigned to the new familyAssigned to the new family
PapillomaviridaePapillomaviridae in 2004.in 2004.
► 12 genera, of which 5 infect humans, other12 genera, of which 5 infect humans, other
seven infects only animals.seven infects only animals.
► Human papillomavirus belong to generaHuman papillomavirus belong to genera
αα,,ββ,,γγ,,μμ,,νν..

7. HPV----- BiologyHPV----- Biology
►Small, non enveloped, icosahedral particles.Small, non enveloped, icosahedral particles.
► Replicate in squamous epithelial cellsReplicate in squamous epithelial cells
► 52-55 nm size.52-55 nm size.
► Genome consists of a single molecule of dsGenome consists of a single molecule of ds
circular DNA appx. 8000 bp size.circular DNA appx. 8000 bp size.
► Capsid contains 72 capsomers.Capsid contains 72 capsomers.

8. HPV----- BiologyHPV----- Biology
► Capsid contains 2 structural proteins:Capsid contains 2 structural proteins:
L1 (major capsid protein): 55kd, 80% ofL1 (major capsid protein): 55kd, 80% of
total viral proteinstotal viral proteins
L2 (Minor): 70kdL2 (Minor): 70kd
Expression of L1 alone or a combination ofExpression of L1 alone or a combination of
L1 and L2 will result in production of VirusL1 and L2 will result in production of Virus
like particles (VLP) without the DNA.like particles (VLP) without the DNA.

9. HPV----- Biology: GenomeHPV----- Biology: Genome
► All the Open Reading Frames are located on oneAll the Open Reading Frames are located on one
strand of viral DNAstrand of viral DNA
► Ten designated translational ORF, classified intoTen designated translational ORF, classified into
E and L ORF.E and L ORF.
► E Region: Encode viral regulatory proteins, andE Region: Encode viral regulatory proteins, and
those needed for initiating viral DNA replication. Inthose needed for initiating viral DNA replication. In
non-productively infected cells.non-productively infected cells.
► L Region: Viral capsid proteins in productivelyL Region: Viral capsid proteins in productively
infected cells.infected cells.

10. 10001000
20002000
30003000
40004000
50005000
60006000
70007000
7904/17904/1
E6 E7
E1
E2
E4
E5
L2
GenomeGenome
•8 kilobase
circular dsDNA.
Persists as
episome (doesn’t
integrate into
cellular DNA) L1
•One coding strand.
Genome is divided into
Late and Early regions

11. •genome encapsidation
•membrane penetration
•post-entry trafficking
•virion formation
•cell association
1000
2000
3000
4000
5000
6000
7000
7904/1
E6 E7
E1
E2
E4
E5
Capsid GenesCapsid Genes
L1
L2

12. 1000
2000
3000
4000
5000
6000
7000
7904/1
E1
E2
E4
OncogenesOncogenes
L1
L2
E6
E7
•Together the
viral oncogenes
immortalize the
cell and prime it
for viral DNA
replication by
disrupting the
cell cycle.
E5

13. 1000
2000
3000
4000
5000
6000
7000
7904/1
E1
E2
E4
DNA Handling GenesDNA Handling Genes
L1
L2
E6
E7
•Helicase,
recruits
cellular DNA
polymerase
E5
LCR
•Transcriptional
regulation
•recruit E1 to Ori,
•tethers viral DNA to
chromosomes
during cell division
Long Control
Region/Upstream Regulator
region: Origin of DNA
replication.

14. HPV Replication: The Life CycleHPV Replication: The Life Cycle
Attachment, Entry, UncoatingAttachment, Entry, Uncoating
Viral TranscriptionViral Transcription
Virus Assembly and ReleaseVirus Assembly and Release

15. Attachment, Entry, UncoatingAttachment, Entry, Uncoating
► Basal kerationocytes are infected first----Basal kerationocytes are infected first----
wounds, abrasions.wounds, abrasions.
► Receptor/s to which HPV binds is not veryReceptor/s to which HPV binds is not very
clear:clear: αα6 integrin, heparan, cell surface6 integrin, heparan, cell surface
glycosaminoglycansglycosaminoglycans
► Enters the cell by clathrin dependentEnters the cell by clathrin dependent
receptor mediated endocytosis.receptor mediated endocytosis.

16. Attachment, Entry, UncoatingAttachment, Entry, Uncoating
► Dis-assembly and exposure of viral genomeDis-assembly and exposure of viral genome
occurs within endosomesoccurs within endosomes
► L2 and the genome escape into cytoplasm andL2 and the genome escape into cytoplasm and
enter the nucleus ------enter the nucleus ------
L2 Functions:L2 Functions: Enhances nuclear import of viralEnhances nuclear import of viral
genomegenome;; localization of the genome to thelocalization of the genome to the
transcriptionally active nuclear domain 10;transcriptionally active nuclear domain 10;
mediates endosomal escapemediates endosomal escape;; interacts withinteracts with
syntaxin 18(End Ret Protein) needed for transportsyntaxin 18(End Ret Protein) needed for transport
across cytoplasm.across cytoplasm.

17. Infectious Entry PathwayInfectious Entry Pathway
Step 8: L2 drags viralStep 8: L2 drags viral
genome to nucleusgenome to nucleus
nuclear pore
DNA
Tubulin
Actin?L2

18. Immortalization andImmortalization and
TransformationTransformation
► A few HPV types can immortalize primaryA few HPV types can immortalize primary
human fibroblasts, human foreskinhuman fibroblasts, human foreskin
kerationcytes or human cervical epithelialkerationcytes or human cervical epithelial
cells.cells.
► The resulting cell lines display alteredThe resulting cell lines display altered
growth properties and resistant in thegrowth properties and resistant in the
response to signals for terminalresponse to signals for terminal
differentiation.differentiation.

19. Immortalization andImmortalization and
TransformationTransformation
►Transformation is "Transformation is "the introduction ofthe introduction of
inheritable changes in a cell causing changes ininheritable changes in a cell causing changes in
the growth phenotype and immortalisation". "thethe growth phenotype and immortalisation". "the
introduction of inheritable changes in a cellintroduction of inheritable changes in a cell
causing changes in the growth phenotype andcausing changes in the growth phenotype and
immortalisation".immortalisation".

20. Immortalization andImmortalization and
TransformationTransformation
The transformed cells have abnormal growth parameters andThe transformed cells have abnormal growth parameters and
behaviors:behaviors:
► Immortality: can grow indefinitelyImmortality: can grow indefinitely
► Reduced requirement for serum growth factorsReduced requirement for serum growth factors
► Loss of capacity for growth arrest upon nutrient deprivationLoss of capacity for growth arrest upon nutrient deprivation
► High saturation densitiesHigh saturation densities
► Loss of contact inhibitionLoss of contact inhibition
► Anchorage independent (can grown in soft agar)Anchorage independent (can grown in soft agar)
► Altered morphology (rounded and refractile)Altered morphology (rounded and refractile)
► Tumorogenic: can cause tumors when transplanted intoTumorogenic: can cause tumors when transplanted into
animalsanimals

21. The cell cycle: Role ofThe cell cycle: Role of RbRb
Cell growth regulated
by an internal timer:
cell cycle
Divided into 4 phases
1. G1: cell growth,
restriction point
2. S: DNA synthesis
3. G2: preparation for
cell division
4. M: Mitosis

22. Cell cycle is controlled by the cyclin-Cdk machinery
Different cyclins and cyclin dependent kinases expressed at different
stages of the cell cycle.
Rb protein:
phosphorylation status of
Rb used to control cell
cycle
•Rb phosphorylation:
allows passage of G1
restriction point, entry
into S-phase
•Rb
dephosphorylation:
signals end of M
phase. This stage
represents the active
stage of Rb because it
inhibits cell cycle
progression.

23. RbRb
► pRb functions in growth control by its bindingpRb functions in growth control by its binding
ability and inhibition of various transcription factorsability and inhibition of various transcription factors
namely E2 F-1and cMyc proteins.namely E2 F-1and cMyc proteins.
► These cMyc and E2 F-1 proteins activate some ofThese cMyc and E2 F-1 proteins activate some of
the essential genes which are required for DNAthe essential genes which are required for DNA
synthesis.synthesis.
► The HPV infected cell typically shows that pRb isThe HPV infected cell typically shows that pRb is
inactive throughout in association with binding ofinactive throughout in association with binding of
the E7 proteins.the E7 proteins.
► This decreased or inappropriate release ofThis decreased or inappropriate release of
transcription factors favours the deregulatedtranscription factors favours the deregulated
expression of genes which are related with normalexpression of genes which are related with normal
control and cell divisioncontrol and cell division ..

24. Cell Regulation:Cell Regulation: p53p53
► p53 is a tumor suppressor genep53 is a tumor suppressor gene
► Determines response of cells to DNA damage andDetermines response of cells to DNA damage and
hypoxiahypoxia
► p53 promotes eitherp53 promotes either
 Cell cycle arrest (until problem is fixed)Cell cycle arrest (until problem is fixed)
 Apoptosis (unfixable problem)Apoptosis (unfixable problem)
► Virus infection is a stress that turns on p53Virus infection is a stress that turns on p53
► Proteins from many viruses mislocalize or blockProteins from many viruses mislocalize or block
p53 e.g. Adenoviruses, papillomaviruses,p53 e.g. Adenoviruses, papillomaviruses,
polyomavirusespolyomaviruses

25. HPV and CancerHPV and Cancer
► Genital Cancers: Cervix, Vulva, Vagina,Genital Cancers: Cervix, Vulva, Vagina,
Penis, Anus.Penis, Anus.
► Skin Cancer in patients withSkin Cancer in patients with
epidermodysplastic verruciformis.epidermodysplastic verruciformis.
► Oral and tonsillar CancersOral and tonsillar Cancers
► Malignant progression of RecurrentMalignant progression of Recurrent
Respiratory Papillomatosis.Respiratory Papillomatosis.

26. Worldwide Incidence ofWorldwide Incidence of
Cancers Attributable to HPVCancers Attributable to HPV

27. Cervical cancer: 0.500 million in 2002
1
High-grade precancerous lesions:
10 million
2
Low-grade cervical lesions:
30 million
2
Genital warts: 30 million
3
AttributabletooncogenicHPVtypes
HPV infection without
detectable abnormalities:
300 million
2
Attributabletonon-oncogenicHPVtypes
Very high global burden
of HPV-related diseases
HPV disease burdenHPV disease burden
1.Parkin et al. 2005
2.WHO 1999
3.WHO 1990
HPV 16, 18 and othersHPV 16, 18 and others
HPV 6, 11 and othersHPV 6, 11 and others

28. HPV and CancerHPV and Cancer
►Greater than 100 subtypesGreater than 100 subtypes
 About 15-20 cancer related types (type 16 andAbout 15-20 cancer related types (type 16 and
18 associated with 67% of cervical cancer)18 associated with 67% of cervical cancer)
 All of these 15-20 subtypes associated withAll of these 15-20 subtypes associated with
99.7% of cervical cancer99.7% of cervical cancer
►Types 16,18, 31,33,35, 39, 45,Types 16,18, 31,33,35, 39, 45,
51,52,56,58,59,68, 72, (26,53,66): HIGH51,52,56,58,59,68, 72, (26,53,66): HIGH
RISKRISK

29. The HPV Oncoproteins:The HPV Oncoproteins: E6E6
► 150 amino acids in size.150 amino acids in size.
► Both high- and low-risk HPV E6 have similarBoth high- and low-risk HPV E6 have similar
transcription activity, those from low risk typestranscription activity, those from low risk types
have little/no transforming activity.have little/no transforming activity.
► Complexes with p53 and blocks theComplexes with p53 and blocks the
transcriptional activity of p53. For binding with p53transcriptional activity of p53. For binding with p53
it needs a cellular protein of 100KD ----E6-AP.it needs a cellular protein of 100KD ----E6-AP.

30. The HPV Oncoproteins:The HPV Oncoproteins: E6E6
► The E6-E6 AP complex targets ubiquitin targetedThe E6-E6 AP complex targets ubiquitin targeted
substratessubstrates
► This results in ubiquitin targeted degradation of p53This results in ubiquitin targeted degradation of p53
protein.protein.
► The host cell is allowed to go from the p53 associatedThe host cell is allowed to go from the p53 associated
negative growth control.negative growth control.
► E6 also activate expression of hTERT, the catalyticE6 also activate expression of hTERT, the catalytic
subunit of telomerase : Activation of cellular Telomerasesubunit of telomerase : Activation of cellular Telomerase
(synthesis of telomere) resulting in maintenance of(synthesis of telomere) resulting in maintenance of
telomere length.telomere length.

31. The HPV Oncoproteins:The HPV Oncoproteins: E7E7
► E7 protein is small nucleoprotein of 100E7 protein is small nucleoprotein of 100
amino acidsamino acids
► It can bind to zinc and is phosphorylated byIt can bind to zinc and is phosphorylated by
casein kinase IIcasein kinase II
► Can bind to cellular regulatory proteinCan bind to cellular regulatory protein
product of retinoblastoma tumourproduct of retinoblastoma tumour
suppressor gene pRB and related proteinssuppressor gene pRB and related proteins
p107 and p130.p107 and p130.

32. The HPV Oncoproteins:The HPV Oncoproteins: E7E7
► E7 binds preferentially to the hypo (de-)E7 binds preferentially to the hypo (de-)
phosphorylated form of pRb resulting in itsphosphorylated form of pRb resulting in its
functional inactivation through the release of E2Ffunctional inactivation through the release of E2F
transcription factor. This permits the cell to entertranscription factor. This permits the cell to enter
into the S phase of cell cycle resulting in cellinto the S phase of cell cycle resulting in cell
proliferation.proliferation.
► It also interacts with cyclin dependent kinaseIt also interacts with cyclin dependent kinase
inhibitors like p21, p27 which helps the cell ininhibitors like p21, p27 which helps the cell in
overcoming TGF-overcoming TGF-ββ associated growth arrest.associated growth arrest.

33. HPV virologyHPV virology
NonproliferatingNonproliferating cellcell
p53p53
pRBpRB
G0: quiescent stateG0: quiescent state
G1: gapG1: gap
phasephase
G2: gapG2: gap
phasephase
Cells exitCells exit
cycle herecycle here
M phase:M phase:
mitosismitosis
S phase: DNAS phase: DNA
synthesissynthesis
HPV stimulates proliferationHPV stimulates proliferation
HPVHPV
G1: gapG1: gap
phasephase
G2: gapG2: gap
phasephase
M phase:M phase:
mitosismitosis
Non-stopNon-stop
proliferationproliferation
P53P53++E6E6 pRBpRB++E7E7

34. Normal
Cervix
HPV
Infection
Persistent
HPV
Infection
Cervical
Dysplasia
(pre-cancer)
Cervical Cancer
Cervical Cancer BiologyCervical Cancer Biology

35. Classification of Histological Findings:Classification of Histological Findings:
Cervical Intraepithelial NeoplasiaCervical Intraepithelial Neoplasia
► Cervical intraepithelial neoplasia (CIN)Cervical intraepithelial neoplasia (CIN)11
 CIN 1: Mild dysplasia; includes condyloma (anogenitalCIN 1: Mild dysplasia; includes condyloma (anogenital
warts)warts)
 CIN 2: Moderate dysplasiaCIN 2: Moderate dysplasia
 CIN 3: Severe dysplasia; includes CISCIN 3: Severe dysplasia; includes CIS
1. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press;
2002:569–612. 2. Ostor AG. Int J Gynecol Pathol. 1993;12:186–192.
CINCIN11
NormalNormal
CIN 1CIN 1
(condylom(condylom
a)a)
CIN 1CIN 1
(mild(mild
dysplasia)dysplasia)
CIN 2CIN 2
(moderate(moderate
dysplasia)dysplasia)
CIN 3CIN 3
(severe dysplasia/CIS)(severe dysplasia/CIS)
InvasiveInvasive
CancerCancer
Histology ofHistology of
squamoussquamous
cervicalcervical
epitheliumepithelium11
CIN caused by HPV can clear without treatment.2

36. Life Cycle - Initial Infection (Skin)Life Cycle - Initial Infection (Skin)
micro-traumamicro-trauma
EpidermisEpidermis
(Keratinocytes)(Keratinocytes)
BasalBasal
CellsCellsBasementBasement
MembraneMembrane
DermisDermis
virionsvirions
Slide courtesy M. Kast

37. Gene Expression (Wart)Gene Expression (Wart)
BasementBasement
MembraneMembrane
EpidermisEpidermis
DermisDermis
Viral ProteinsViral Proteins
Early only
Capsid &
Early
NoneNone
Progeny virionsProgeny virions

38. Immune EvasionImmune Evasion
BasementBasement
MembraneMembrane
Draining LymphaticsDraining Lymphatics
EpidermisEpidermis
DermisDermis
LangerhansLangerhans
cellscells
DendriticDendritic
cellscells

39. Doorbar, J Clin Virol 32:7-15, 2005
Progression to Cancer is Accompanied byProgression to Cancer is Accompanied by
Deregulation of Viral Gene ExpressionDeregulation of Viral Gene Expression
CIN 1 CIN 2 CIN 3
Common molecular events:
•Viral genome integration into cellular DNA
•Loss of E2 leads to increased E6/E7 expression
•Loss of L1, L2 expression. Therefore, current
vaccine can’t clear pre-cancerous lesions.

40. Natural History of HPV Infection:Natural History of HPV Infection:
Surrogate Markers for Cervical CancerSurrogate Markers for Cervical Cancer
0 to 5 Years Up to 20 Years
Initial
HPV
Infection
CIN 1
Cleared HPV Infection
Sq. Cell
Carcinoma
CIN 2
Persistent
Infection
CIN 3
Adeno-
CarcinomaAIS

41. HPV and Cancer: TheHPV and Cancer: The
ConclusionConclusion
Cervical and other genital cancers are composed of cells that have
lost the ability to differentiate, a process necessary for productive
replication of HPVs.
 In addition, cervical cancers can often contain integrated HPV
genomes rather than episomes and viral DNA needs to exist episomally
in order to be productively replicated.
 Not surprisingly, cancer cells do not produce HPV virions.
 Since a primary goal of infection is to generate new virions, the
induction of cancers by HR HPV types is a ‘dead end’ for the virus.
 In fact, it would seem to be in the interest of the virus to avoid
promoting malignancy.
 However, the persistent nature of HPV infections allows cellular
genetic changes to accumulate over extended periods of time until a
combination of genetic abnormalities has occurred allowing cancer to
develop.

42. HPV and Cancer: TheHPV and Cancer: The
ConclusionConclusion
► E6 and E7 themselves contribute to the accumulation ofE6 and E7 themselves contribute to the accumulation of
mutations in the cellular genome by promoting genomicmutations in the cellular genome by promoting genomic
instability during persistent infectionsinstability during persistent infections
► E6 and E7 induce centrosomal abnormalities resulting inE6 and E7 induce centrosomal abnormalities resulting in
abnormal segregation of chromosomes and aneuploidy.abnormal segregation of chromosomes and aneuploidy.
E7 causes centrosome reduplication leading to abnormalE7 causes centrosome reduplication leading to abnormal
numbers of centrosomesnumbers of centrosomes
► In addition, abrogation of cell cycle checkpoints throughIn addition, abrogation of cell cycle checkpoints through
the targeting of p53 and pRb family members allowsthe targeting of p53 and pRb family members allows
retention of cells with chromosomal abnormalitiesretention of cells with chromosomal abnormalities
► What advantage the virus gains by promoting cellularWhat advantage the virus gains by promoting cellular
genome instability is not clear.genome instability is not clear.

43. THE VACCINETHE VACCINE
►Work started in 1980s, CollaborationWork started in 1980s, Collaboration
between Georgetown University medicalbetween Georgetown University medical
centre, Rochester University, University ofcentre, Rochester University, University of
Queensland, and National Cancer Institute.Queensland, and National Cancer Institute.
► GARDASIL (Merck) approved by FDAGARDASIL (Merck) approved by FDA
(USA) in 2006.(USA) in 2006.
► CERVARIX (GSK) approved in Australia,CERVARIX (GSK) approved in Australia,
EU (2007) and in USA in 2009.EU (2007) and in USA in 2009.

44. The VaccineThe Vaccine
► Subunit Vaccines, containing hollow Virus LikeSubunit Vaccines, containing hollow Virus Like
Particles (VLPs) containing the L1 Capsid protein..Particles (VLPs) containing the L1 Capsid protein..
► Generated by recombinant genetic engineering inGenerated by recombinant genetic engineering in
yeasts.yeasts.
► Amorphous Aluminum Hydroxyphosphate SulfateAmorphous Aluminum Hydroxyphosphate Sulfate
Adjuvant (225Adjuvant (225 μμg per dose)g per dose)
► No Mercury preservativeNo Mercury preservative
► Storage: 2 to 8Storage: 2 to 8 OO
CC
► Gardasil: HPV 6,11,16, 18.Gardasil: HPV 6,11,16, 18.
► Cervarix: HPV 16,18.Cervarix: HPV 16,18.

45. The VaccineThe Vaccine
► CervarixCervarix has 20 mcg each of HPV 16 and HPV 18has 20 mcg each of HPV 16 and HPV 18
L1 proteins;L1 proteins; GardasilGardasil has 20 mcg of HPV 6, 40has 20 mcg of HPV 6, 40
mcg of HPV 11, 40 mcg of HPV 16, and 20 mcg ofmcg of HPV 11, 40 mcg of HPV 16, and 20 mcg of
HPV 18HPV 18
► Target Population: Routine ImmunizationTarget Population: Routine Immunization
Cervarix: Females 10-25 yrs, Gardasil: Females 9-Cervarix: Females 10-25 yrs, Gardasil: Females 9-
26 yrs.26 yrs.
► ACIP: Non routine immunization of males 9-18ACIP: Non routine immunization of males 9-18
yrs.yrs.
► Both Vaccines: THREE Doses; 0, 1-2 mts, 6 mts.Both Vaccines: THREE Doses; 0, 1-2 mts, 6 mts.

46. The VaccineThe Vaccine
► Injection Site:Injection Site:
 Upper arm (Deltoid region)Upper arm (Deltoid region)
 Thigh (higher anterolateral area)Thigh (higher anterolateral area)
►0.5 mL volume0.5 mL volume IM injectionIM injection
►Package:Package:
 Prefilled syringePrefilled syringe
 Shake well before useShake well before use
► Appx Cost: ~ US$ 450 for full vaccinationAppx Cost: ~ US$ 450 for full vaccination

47. Prophylactic VaccineProphylactic Vaccine
► Both are quite effective at preventing HPV 16/18Both are quite effective at preventing HPV 16/18
persistent infections and the associated CIN 2+persistent infections and the associated CIN 2+
caused in women of 15-26 years oldcaused in women of 15-26 years old with nowith no
current HPV infection at the time of initialcurrent HPV infection at the time of initial
vaccinationvaccination
► However, if the girl/woman is currently infectedHowever, if the girl/woman is currently infected
with and producing the HPV 16 or 18 virus at thewith and producing the HPV 16 or 18 virus at the
time of vaccination, the vaccines will not stop thetime of vaccination, the vaccines will not stop the
HPV from progressing to CIN 2+.HPV from progressing to CIN 2+.
► They show no therapeutic efficacy against currentThey show no therapeutic efficacy against current
infectioninfection

48. MECHANISM OF ACTION

49. HPV L1 VLP vaccineHPV L1 VLP vaccine
Mimic natural virion structure generate potent immune responseMimic natural virion structure generate potent immune response

50. HPV L1 VLP vaccineHPV L1 VLP vaccine
APC
HPV L1 VLP
IgG
B T
APC present
MHC-Ag complex
and co-stimulation
signal
Plasma cellPlasma cell
Plasma cellPlasma cell
Ig switch
IgG
IgG
Immunized by HPV L1 VLP vaccine
The protection against challenge with infectious
virus is elicited by high titers of neutralizing
serum antibody(IgG) induced by these vaccine
Future HPV infection
Adaptive
Immunity

51. Protective EfficacyProtective Efficacy
► The FUTURE I (Females United to Unilaterally
Reduce Endo/Ectocervical Disease)Study: Three-
year phase 3 trial examined the effectiveness of
the quadrivalent vaccine in preventing genital
diseases associated with HPV types 6, 11, 16, and
18.
► The vaccine was nearly 100 percent effective in
preventing precancerous lesions (CIN 2 and CIN
3) and genital warts when given to unexposed
women. (NEJM 2007)

52. Protective EfficacyProtective Efficacy
► FUTURE II trial, showed that the quadrivalent
vaccine is 98 percent effective in preventing high-
grade precancerous cervical lesions (HPV 16, 18)
in unexposed women over a three-year period
( NEJM 2007)
► PATRICIA (Papilloma Trial Against Cancer in
Young Adults) trial : The bivalent vaccine is 98
percent effective in preventing precancerous
cervical lesions (CIN 2 and CIN 3) caused by HPV
types 16 and 18, and may provide some cross-
protection against types 31, 33, and 45.38
(Lancet, 2009)(Lancet, 2009)

53. Measurement of induced antibodies
to HPV 16 and 18 by Cervarix and
Gardasil one month after the 3rd
dose (month 7) among 18-45 year
old women. This figure shows that
Cervarix induces a significantly
higher antibody response after three
doses of vaccine than Gardasil

54. Protective Efficacy: Cross-ProtectionProtective Efficacy: Cross-Protection
► Gardasil potentially offers disease
protection against additional oncogenic
HPV types 31, 33, 45, 52, 58 (43-62%)
► Cervarix (Bivalent): Cross protection 31-
60%.

55. Duration of ProtectionDuration of Protection
► At least five years.At least five years.
► Phase II trials provide the longest follow-upPhase II trials provide the longest follow-up
data for Gardasil at 5 years and for Cervarixdata for Gardasil at 5 years and for Cervarix
at 8.4 years (Villa et al., 2006; The GSKat 8.4 years (Villa et al., 2006; The GSK
HPV Vaccine 007 Study Group, 2010).HPV Vaccine 007 Study Group, 2010).
► Modeling has shown that HPV vaccinesModeling has shown that HPV vaccines
must maintain their near 100% efficacy for amust maintain their near 100% efficacy for a
full 15 years, at minimum, in order forfull 15 years, at minimum, in order for
cervical cancers to be preventedcervical cancers to be prevented

56. Sustained clinical efficacySustained clinical efficacy and antibody titerand antibody titer
forfor at leastat least 5 years5 years
10 000
1 000
100
10
GMT (mMU/mL)
GARDASIL
Natural infection
0 7 12 18 24 30 36 54 60
months
GARDASIL 100%
1st
2nd
3rd
Dose
Clinicalefficacy*
Neutralisingantibodies
(HPVtype16)
18
5 years
* against infection, CIN (Cervical intraepithelial neoplasia) and genital warts
due to
HPV types 6,11,18; 5 yrs follow up (after dose 1) of a subset (241 women,
vaccine
& placebo) from a phase II efficacy study
Villa L High Sust Eff Proph Quad HPV Vacc 5 Year Followup Br J
Can 2006 95 1459

57. Duration of ProtectionDuration of Protection
► Induced antibodies against the L1 VLP for HPVInduced antibodies against the L1 VLP for HPV
16 are high and are sustained for both Cervarix16 are high and are sustained for both Cervarix
and Gardasil for their 8.4 years and 5 years ofand Gardasil for their 8.4 years and 5 years of
protection, respectivelyprotection, respectively
► Induced antibodies for HPV 18 from Gardasil fallInduced antibodies for HPV 18 from Gardasil fall
quickly after peak with 35% of women having noquickly after peak with 35% of women having no
measurable antibody titers to HPV 18 at 5 years.measurable antibody titers to HPV 18 at 5 years.
Cervarix titers remain several fold above naturalCervarix titers remain several fold above natural
infection titer for HPV 18.infection titer for HPV 18.
► Natural infection titers are not protective againstNatural infection titers are not protective against
future type specific infections.future type specific infections.

58. SafetySafety
► Autoimmune demyelinating neurologic sequelae afterAutoimmune demyelinating neurologic sequelae after
Gardasil administration, resulting in blindness, paralysis,Gardasil administration, resulting in blindness, paralysis,
and death (GB Syndrome): 13 Casesand death (GB Syndrome): 13 Cases
► Deaths: 11 casesDeaths: 11 cases
► Causal relationship between the events and theCausal relationship between the events and the
vaccinationvaccination has not beenhas not been establishedestablished
► From the studies, number of death cases wereFrom the studies, number of death cases were notnot
differentdifferent between vaccine groups and placebo groupsbetween vaccine groups and placebo groups
► Total doses: >18 millionTotal doses: >18 million
► CDC and FDA were satisfied with the safety dataCDC and FDA were satisfied with the safety data
► Large scale clinical trials have also shown well toleratedLarge scale clinical trials have also shown well tolerated
safety profile.safety profile.

59. Controversy: IndiaControversy: India
► Gardasil dissemination programs in AndhraGardasil dissemination programs in Andhra
Pradesh and Gujarat were suspended in AprilPradesh and Gujarat were suspended in April
2010 by the Indian government despite an annual2010 by the Indian government despite an annual
cervical cancer incidence rate of 28 women percervical cancer incidence rate of 28 women per
100,000 which is over three times that of the US100,000 which is over three times that of the US
and seven times that of Finland.and seven times that of Finland.
► The most disquieting objection to the program,The most disquieting objection to the program,
was the lack of information provided to the publicwas the lack of information provided to the public
so that each participant could be afforded theso that each participant could be afforded the
opportunity for informed decision making aboutopportunity for informed decision making about
their cervical cancer protection.their cervical cancer protection.

60. Future Direction: TherapeuticFuture Direction: Therapeutic
VaccineVaccine
The oncoprotein E7, is expressed in transformedThe oncoprotein E7, is expressed in transformed
cells but thought to represent a poorlycells but thought to represent a poorly
immunogenic antigen.immunogenic antigen.
► Many in vivo studies indicate that miceMany in vivo studies indicate that mice
vaccinated using a plasmid-encoded E7 fusionvaccinated using a plasmid-encoded E7 fusion
protein are protected against in vivo tumorprotein are protected against in vivo tumor
challenge.challenge.

61. Future Direction: TherapeuticFuture Direction: Therapeutic
VaccineVaccine
► Researches demonstrated that protectionResearches demonstrated that protection
against tumor growth is associated with theagainst tumor growth is associated with the
development of a CD4-regulated, E7-specificdevelopment of a CD4-regulated, E7-specific
CTL activity mediated by CD8 cellsCTL activity mediated by CD8 cells
► Recent researches are focused on aRecent researches are focused on a DNA-DNA-
based vaccinationbased vaccination protocol aimed at inducingprotocol aimed at inducing
an efficient anti-E7 immune response in vivo.an efficient anti-E7 immune response in vivo.

62. Eradication of Cervical Cancer andEradication of Cervical Cancer and
HPV Related DiseasesHPV Related Diseases
Not a Dream Anymore…Not a Dream Anymore…