Welcoming remarks by Dr Osborne E Nyandiva on Symposium: Cervical cancer and its prevention Co-Presenter Dr Giama. We are happy to present to you this very crucial discussion on Cancer. Cervical cancer is a type of cancer that develops in a woman's cervix (the entrance to the womb from the vagina). Cancer of the cervix often has no symptoms in its early stages. If you do have symptoms, the most common is unusual vaginal bleeding, which can occur after sex, in between periods or after the menopause.

1. 1
CERVICAL CANCER & ITSCERVICAL CANCER & ITS
PREVENTIONPREVENTION
WELCOME!!!!!!!WELCOME!!!!!!!
Educational Program 2016 GMC -CME 1
DR ABDULCADIR M GIAMADR ABDULCADIR M GIAMA
THE EXECUTIVETHE EXECUTIVE
DIRECTOR &DIRECTOR &
PRESIDENT,GLOBALPRESIDENT,GLOBAL
SCIENCE UNIVERSITYSCIENCE UNIVERSITY
DRDR
OSBORNENYANDIVAOSBORNENYANDIVA
Ph.D-CndPh.D-Cnd
THE CONSULTANTTHE CONSULTANT
PATHOLOGISTPATHOLOGIST

2. 2
Sad but True…Sad but True…
In Somalia, 50 womenIn Somalia, 50 women
die each day due todie each day due to
Cervical cancerCervical cancer

3. 3

4. 4
For you & your daughter …..aFor you & your daughter …..a
wonderful giftwonderful gift
Guard Yourself meansGuard Yourself means
Protect yourselfProtect yourself
very special programmevery special programme
to prevent cervical cancer.to prevent cervical cancer.

5. 5
where is cervix in woman?where is cervix in woman?
Educational Program 2015 5
CERVIX

6. 6
What is cancer?What is cancer?
• Uncontrolled growth of abnormal cells inUncontrolled growth of abnormal cells in
any part of the body.any part of the body.
• Generally due toGenerally due to
1. chemicals (e.g. From smoking )1. chemicals (e.g. From smoking )
2. radiation2. radiation
3. micro-organisms (e.g. Bacteria, viruses)3. micro-organisms (e.g. Bacteria, viruses)

7. 7
Somalia ~10,200
World ~ 4,93,000
Somalia ~27% of new
Cervical Cancer cases in world
Somalia ~ 4,000
World ~ 2,73,000
Somalia ~27%
Rest of World - 73%
Somalia ~27% of deaths
due to Cervical Cancer in world
Rest of World - 73%
India - 27%
Cervical Cancer – Disease Burden
New Cervical Cancer Cases Deaths due to Cervical cancer
Somalia ~27%
Rest of World - 73%

8. 8
Incidence ( Women of all ages) – CervicalIncidence ( Women of all ages) – Cervical
Cancer vs. other CancersCancer vs. other Cancers
2. 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/hpvcentre

9. 9
HPV 16
HPV 18
HPV 6
HPV 11
Cancer causing Types1,2,4 Non-cancer causing types1,2
• >75% of Cervical Cancer5
• >50% of Vaginal & Vulvar Cancer5
90% 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/hpvcentre
Human Papillomavirus (HPV)

10.  Anogenital Disease: cervix, vulva, vagina, anus, penis
 Condylomata accuminatum
 Squamous intraepithelial neoplasia
 Cancer
 Head/Neck Disease:
 Mouth, tongue, tonsils
 Sinuses
 Oropharangeal
 Respiratory mucosa (children; type 6, 11)
 Cancer: usually HPV 16
 Cofactors: Smoking, Alcohol

12. HPV
Infection
Cervical
Lesions
Normal
Development of Precancerous lesions
CIN1, CIN2 & CIN3
Invasive
Cancer
Ranges
from
Measured by HPV DNA
detection in cervical cells
Relative frequency
increases with severity of
lesion

13. Long term use of Hormonal Contraceptive
-> 5-9yrs :: 3 times Risk
-> 10yrs or more :: 4 times Risk
High Parity :: 4 times Risk
Early initiation of Sexual Activity
Multiple Sex PartnersTobacco Smoking (Both active & passive)
HIV Infection
Other STI’s
->Chlamydia Trachomatis
-> HSV 2
Immune Suppression
Low S/E status ; Diet poor in anti oxidants

15. Normal
Cervix
HPV
Infection
Pre-cancer Cancer
Infection
Progression Invasion
RegressionClearance
 Persistence

16. 16
CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)
as Seen in Colposcopyas Seen in Colposcopy
CIN 1 CIN 2 CIN 3
Photo courtesy of Dr. Njue Photo courtesy of Dr. Njue Dr.Njue
Colposcopy findings confirmed by histologyColposcopy findings confirmed by histology11

17. 17
How HPV infection can occur?How HPV infection can occur?
 Through sexual intercourseThrough sexual intercourse,, verticalvertical
transmission i.e. mother to childtransmission i.e. mother to child &&
fomites.fomites.
 It is found that inIt is found that in every 10 women 8every 10 women 8
women might have HPV infectionwomen might have HPV infection atat
anytime in life.*anytime in life.*
Educational Program 2009 17

18. 18
Beware of this symptomsBeware of this symptoms
Consult your doctor immediately if you haveConsult your doctor immediately if you have
• Continuous vaginal discharge,inspite of treatmentContinuous vaginal discharge,inspite of treatment
• Foul smelling, thick discharge,Foul smelling, thick discharge,
• Repeated vaginitis and UTIRepeated vaginitis and UTI
• Post coital bleeding(bleeding after sex)Post coital bleeding(bleeding after sex)
• Non healing or recurrent cervical erosionNon healing or recurrent cervical erosion
• Irregular or intermenstrual bleeding specially in preIrregular or intermenstrual bleeding specially in pre
menopausal phasemenopausal phase

19. 19
Cervical cancer screeningCervical cancer screening
• Chronic painChronic pain
• distensiondistension
• loss of weightloss of weight
• Heavy prolong bleeding ,before or duringHeavy prolong bleeding ,before or during
menopausal agemenopausal age
• Post menopausal bleeding-importantPost menopausal bleeding-important
• Cervical polypCervical polyp
• tumor during or before menopause agetumor during or before menopause age

20. 20Educational Program 2009 20
Is it possible
to get
protection
against
cervical cancer?

21. Cervical Cancer is now a virtually preventable disease due to
 Early Vaccination
 Screening strategies
 Long natural history
 Cervix is easily accessible

22. 22
Secondary PreventionSecondary Prevention
Screening may help in early detectionScreening may help in early detection
of cervical abnormalitiesof cervical abnormalities

23. 23
What is the use of screeningWhat is the use of screening
program?program?
• Secondary prevention or screeningSecondary prevention or screening
program are helpful in detecting cancerprogram are helpful in detecting cancer
at the early stage hence useful in savingat the early stage hence useful in saving
lives.lives.

24. Visual Inspection
VIA
VILI
Pap Smear
Conventional
LBC
HPV DNA Testing
Cervicography
Pap Net
Polar Probe
Community low
resource
settings
Still Experimental

26. Population WHO ACS/ASCCP/ASCP
Older than 65
years
Recommends against screening
women who have had adequate prior
screening and are not otherwise at
high risk for cervical cancer.
Grade: D recommendation.
Women with evidence of adequate negative prior
screening and no history of CIN2+ within the last 20
years should not be screened. Screening should not
be resumed for any reason, even if a woman reports
having a new sexual partner.
After
hysterectomy
Recommends against screening in
women who have had a
hysterectomy with removal of the
cervix and who do not have a history
of a high-grade precancerous lesion
(i.e. CIN 2 or 3) or cervical cancer.
Grade: D recommendation
Women of any age following a hysterectomy with
removal of the cervix who have no history of CIN2+
should not be screened for vaginal cancer. Evidence
of adequate negative prior screening is not required.
Screening should not be resumed for any reason,
including if a woman reports having a new sexual
partner.
HPV
vaccinated
Women who have been vaccinated
should continue to be screened
Recommended screening practices should not change
on the basis of HPV vaccination status.

27. PAP Smear
 PAP smear sampling of cervix involves scraping of
cervical surface and a portion of non visualised
cervical canal using various sampling devices

28. 28
 disasters “disasters “prevention is better than cureprevention is better than cure’-’-
holds true for cervical cancerholds true for cervical cancer
 This can be achieved by regular healthThis can be achieved by regular health
check up and regular pap smear testcheck up and regular pap smear test
 Pap- smear is cancer screening which isPap- smear is cancer screening which is
easy ,painless and reliable method in whicheasy ,painless and reliable method in which
the discharge from vagina is taken on slidethe discharge from vagina is taken on slide
and sent for examination for presence ofand sent for examination for presence of
abnormal cellsabnormal cells
 Routine pap smear has reduced ca cx by 75%Routine pap smear has reduced ca cx by 75%
in developed worldin developed world
 Repeat pap is advised if it shows abnormalRepeat pap is advised if it shows abnormal
cells & than advised colposcopy & biopsy.cells & than advised colposcopy & biopsy.
 It can give early diagnosis of cancer before itsIt can give early diagnosis of cancer before its
sets in and hence early treatment can avoidsets in and hence early treatment can avoid
diseasedisease

29. Significance of Pap smear
 Detect precancerous & invasive cancer cervix cases in
early stages
 Positive screeners can be selected for selective tests and
management
 With treatment, progression of disease is halted. Thus
morbidity associated with advanced cancer decreases
 Mortality reduces by 20-60 %.
 Helps us to study natural history of disease.

30. Transformation zone
 Cervix develops from 2 embryonic sites
* from Mullerian duct - lined by columnar epithelium
* from urogenital plate - lined by stratified
squamous epithelium
 Point at which columnar and squamous epithelium
meet is called as original squamo-columnar
junction

31. Transformation
zone
 Under influence of estrogen, original SCJ moves
onto the portio.
 Exposure of delicate columnar cells to vaginal
environment leads to squamous metaplasia.
 Transformation zone -
- Area of squamous metaplasia
- Area between original and new SCJ

32. Transformation zone

33. Transformation Zone -TZ
 Exposure of TZ to carcinogens begins the process of
intraepithelial neoplasia
 While exact role of carcinogens in this process remains poorly
understood, it is clear that HPV and cigarette smoking can
cause dysplasia at the TZ
 95% of cervical cancers develop in TZ
 Important to take sample from TZ

34. 34
PAP SMEARPAP SMEAR
• The cells are taken from the cervix region byThe cells are taken from the cervix region by
speculum & spatula, then smear is preparedspeculum & spatula, then smear is prepared
which is then observed under microscope.which is then observed under microscope.
• It is not recommended in virgin females.It is not recommended in virgin females.
• Recommended in every 3 years to all femaleRecommended in every 3 years to all female
aged more than 30 years.aged more than 30 years.

35. How to take a Pap Smear ?
 Spatula is rotated through 360 degrees
maintaining contact with ectocervix
 Do not use too much force [bleeding /pain]
 Do not use too less force [inadequate sample]
 Sample is smeared evenly on the slide and fixed
immediately
 Both sides of spatula are to be smeared

36. How to take a Pap Smear ?
 Endocervical sample is collected using an
endocervical brush
 Insert the cytobrush into canal, so that last bristles
of brush are visible
 Rotate the brush through 180 degrees. [more
rotations increase the chance of bleeding]
 Sample is rolled on the slide and fixed.

37. Fixation of smear
 Fixation is done immediately with
fixative like 95% alcohol or cytofix
spray to avoid air drying
 Spray should be kept at 10 inches, to
avoid destruction of cells by
propellent in the spray
 Smear should monolayer for proper
penetration of cell surface by fixative

38. Fixation of smear
 Fixation is done immediately with
fixative like 95% alcohol or cytofix
spray to avoid air drying
 Spray should be kept at 10 inches, to
avoid destruction of cells by
propellent in the spray
 Smear should monolayer for proper
penetration of cell surface by fixative

39.  Several slides can be prepared from one smearSeveral slides can be prepared from one smear
 Chlamydia, HPV testing can be done at later dateChlamydia, HPV testing can be done at later date
 Reduces the incidence of inadequate and repeat smearsReduces the incidence of inadequate and repeat smears
Liquid Based Cytology

40.  The HPV test is a very accurate way to tell if high-risk HPV is present in a
woman’s cervix.
 This test can use the same sample of cells taken for the Pap test.
 A positive test result means a woman has high-risk HPV.
A positive HPV test does not mean that a woman has
cancer.
A positive HPV test does not mean that a woman has
cancer.

41.  To see if a woman with a borderline Pap test result
(one that shows unusual cells but not dysplasia)
needs additional tests.
 To screen for cervical cancer, along with the Pap
test, in women aged 30 or older.

43. 43
COLPOSCOPYCOLPOSCOPY
Colposcopy is the examination of the cervix &Colposcopy is the examination of the cervix &
vagina with a light magnifying instrumentvagina with a light magnifying instrument
colposcope after the application of a vinegarcolposcope after the application of a vinegar
(acetic acid) to the cervix.(acetic acid) to the cervix.

44. ColposcopyColposcopy
• Magnified visual examination of uterine cervix by a lowMagnified visual examination of uterine cervix by a low
power ,stereoscopic microscope with a powerful lightpower ,stereoscopic microscope with a powerful light
source to help in diagnosis of cervical neoplasia .source to help in diagnosis of cervical neoplasia .
• Key ingradients –observations of features of cervicalKey ingradients –observations of features of cervical
epithelium after application of normal saline , 3-5% diluteepithelium after application of normal saline , 3-5% dilute
acetic acid and Lugol’s iodine solution .acetic acid and Lugol’s iodine solution .
•

45. INDICATIONS OF COLPOSCOPYINDICATIONS OF COLPOSCOPY
• Squamous or glandular cell abnormalitiesSquamous or glandular cell abnormalities
• Persistence of inflammatory cells despite adequate ttPersistence of inflammatory cells despite adequate tt
• Presence of keratinized cells .Presence of keratinized cells .
• VIA +ve and VILLI+veVIA +ve and VILLI+ve
• Evaluation of HPV +ve women .Evaluation of HPV +ve women .
• Postcoital ,postmenopausal bleeding .Postcoital ,postmenopausal bleeding .
• Unhealthy cervix .Unhealthy cervix .
• Treatment and monitoring of women with CINTreatment and monitoring of women with CIN
• Anogenital condylomas ,VIN and VAIN.Anogenital condylomas ,VIN and VAIN.
• DES exposure in utero.DES exposure in utero.

46. Colposcopy - ObjectivesColposcopy - Objectives
 Determines the presence of invasive cancerDetermines the presence of invasive cancer
 Localizes the squamocolumnar junctionLocalizes the squamocolumnar junction
 Identifies the most severe disease for biopsyIdentifies the most severe disease for biopsy
 Evaluates the extent of diseaseEvaluates the extent of disease

47. A method of identifying
outer & inner borders of the transformation zone

49. Post Menopausal Cervix:
Epithelium is pale, brittle, lacks lusture,
shows sub-epithelial petichiae, SCJ not
visualized
The entire new SCJ is visible
colposcopic examination is satisfactory.
the TZ is fully visualized. The metaplastic
squamous epithelium is pinkish-white
compared to the pink original squamous
epithelium

50. Squamous metaplasia
Earliest colposcopic changes in
immature squamous metaplasia
(after 5% AA) in which tips of
columnar villi stain white &
adjacent villi start fusing together
Prominent white line corresponds to
the new SCJ & tongues of immature
Squamous metaplasia a) with crypt
openings at 4-8 o’clock positions
b) after application of AA

51. Immature squamous metaplastic epithelium (narrow arrow)
on the polyp with intervening areas of columnar epithelium
a) after application of AA
The endocervical polyp &
the immature squamous metaplasia
surrounding the os partially take up
iodine.

52. Immature squamous metaplastic epithelium (narrow arrow)
on the polyp with intervening areas of columnar epithelium
a) after application of AA
The endocervical polyp &
the immature squamous metaplasia
surrounding the os partially take up
iodine.

53. LeukoplakiaLeukoplakia
 Usually benignUsually benign
 May obscure an underlyingMay obscure an underlying
neoplasianeoplasia
 Therefore, all patchesTherefore, all patches
observed before application ofobserved before application of
acetic acid must be biopsiedacetic acid must be biopsied
Hyperkeratosis ( Leukoplakia)

54. 54
CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)
as Seen in Colposcopyas Seen in Colposcopy
CIN 1 CIN 2 CIN 3
Photo courtesy of Dr. Njue Photo courtesy of Dr. Njue From ASCP
Colposcopy findings confirmed by histologyColposcopy findings confirmed by histology11

55. Geographic satellite lesion
condyloma low-grade lesion

56. Thin acetowhite lesion with
geographic margins in the upper
lip. Histology indicated CIN 1
Moderately dense acetowhite
lesions with irregular margins in
the anterior & posterior lips ( CIN
1)

57. circumorificial acetowhite CIN 1
lesion with irregular margin & fine mosaics

58. Moderately dense acetowhite lesions with well
defined margins & coarse punctations in the
anterior lip & in 3 o’clock position (CIN 2 lesion
Dense well defined acetowhite
area with regular margins &
coarse mosaic ( CIN 2 lesion )

59. A dense acetowhite lesion with varying colour
intensity &
coarse mosaics (a) in a CIN 2 lesion
Acetowhite lesions with coarse punctation
(a) & mosaics (b) in a CIN 2 lesion

60. A circumoral dense opaque acetowhite area with
coarse mosaics ( CIN 3 lesion)
A dense acetowhite lesion with regular
margin & coarse,
irregular punctation in a CIN 3 lesion.

61. Carcinoma in Situ

62. Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking
mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA
Preclinical invasive
Carcinoma

63. Reddish “angry-looking”, inflamed columnar
epithelium with loss of the
villous structure & with inflammatory exudate
(before application of 5% AA)
Inflammatory lesions of the
Uterine Cervix
Chronic cervicitis: This cervix is
extensively inflammed with a reddish
appearance &
bleeding on touch, there are ill-
defined, patchy acetowhite areas
scattered all over the cervix after the
application of AA

64. TV after Acetic acid
T.V. After Lugol’s
Multiple red spots (a) suggestive of Trichomonas
vaginalis colpitis ( strawberry appearance), after
application of 5% AA
Trichomonas vaginalis colpitis
after application of Lugol’s iodine
(leopard-skin appearance)

65. 65
Primary PreventionPrimary Prevention
by HPV Vaccineby HPV Vaccine
GARDASILGARDASIL®®
[Human Papillomavirus Quadrivalent[Human Papillomavirus Quadrivalent
(Types 6, 11, 16, and 18)(Types 6, 11, 16, and 18)
Vaccine 0.5ml prefilled syringe]Vaccine 0.5ml prefilled syringe]
CERVERIXCERVERIX
[Human Papillomavirus Bivalent[Human Papillomavirus Bivalent
(Types 16 and 18)(Types 16 and 18)
Vaccine 0.5ml prefilled syringe]Vaccine 0.5ml prefilled syringe]
09-2009-GRD-2008-AP-(IN)-1601-SS

66. 66
HPV Vaccines- made byHPV Vaccines- made by
recombinant DNA technologyrecombinant DNA technology

67. 67
INDICATIONINDICATION
FOR GardasilFOR Gardasil
For the prevention ofFor the prevention of
Cervical CancerCervical Cancer
Vulvar/ Vaginal PrecancersVulvar/ Vaginal Precancers
Cervical DysplasiaCervical Dysplasia
Genital WartsGenital Warts
Cerverix is only indicated forCerverix is only indicated for
Cervical cancerCervical cancer

68. 68
EffectivenessEffectiveness
 Gardasil vaccine’s efficacy is 98 toGardasil vaccine’s efficacy is 98 to
100%.100%.
 Cerverix vaccine’s efficacy is 92 toCerverix vaccine’s efficacy is 92 to
94%94%

69. 69
When we can give this vaccine?When we can give this vaccine?
 This vaccine can be given to anyThis vaccine can be given to any
girl above 9 years. Recommendedgirl above 9 years. Recommended
for women of 9-45 years age groupfor women of 9-45 years age group
 TheThe most effective timemost effective time toto
vaccinate girls and young womenvaccinate girls and young women
is before they become sexuallyis before they become sexually
activeactive..
Educational Program 2009 69

70. 70
HowHow many dose recommended?many dose recommended?
 Three dosesThree doses
 First .(as elected date)First .(as elected date)
 Second (after 2 month of first dose)Second (after 2 month of first dose)
 Third (after 6 month of first dose)Third (after 6 month of first dose)
Cerverix – 0,1 & 6Cerverix – 0,1 & 6
Educational Program 2009 70
6
months
2
Months0

71. 71
Side effectsSide effects
• HPV Vaccines demonstrated a favorable safety profile.HPV Vaccines demonstrated a favorable safety profile.
• Following injection-site reactions occurred at a greaterFollowing injection-site reactions occurred at a greater
incidence in the group that received VACCINEincidence in the group that received VACCINE
– Very common:Very common: erythema, pain, and swellingerythema, pain, and swelling..
– Common:Common: pruritispruritis..
– Most injection-site reactions were mild to moderate.Most injection-site reactions were mild to moderate.
– Very Common (≥1/10); Common (≥1/100, <1/10); Uncommon (≥1/1,000, <1/100); RareVery Common (≥1/10); Common (≥1/100, <1/10); Uncommon (≥1/1,000, <1/100); Rare
(≥1/10,000, <1/1,000); Very Rare (<1/10,000)(≥1/10,000, <1/1,000); Very Rare (<1/10,000)
Educational Program 2009 71

72. 72
Special PopulationSpecial Population
PREGNANT WOMENPREGNANT WOMEN
 Because of insufficient trial there is noBecause of insufficient trial there is no
recommendation of this vaccine inrecommendation of this vaccine in
pregnancy.pregnancy.
 If woman gets pregnant after first dose ,thenIf woman gets pregnant after first dose ,then
remaining dose should be taken afterremaining dose should be taken after
deliverydelivery..
LACTATING MOTHERLACTATING MOTHER
 Lactating woman can take this vaccine.Lactating woman can take this vaccine.
Cerverix is not indicated during lactationCerverix is not indicated during lactation
Educational Program 2015 72

73. 73
Is vaccine costly?Is vaccine costly?
 No, if we can see the mortalityNo, if we can see the mortality
rate of the cervical cancer or itsrate of the cervical cancer or its
treatment ,vaccine cost istreatment ,vaccine cost is
nothing against it.nothing against it.
 If we see the modern life style ofIf we see the modern life style of
people ,vaccine cost is nothing.people ,vaccine cost is nothing.
 People give lacks of rupees ofPeople give lacks of rupees of
dowry to their daughters ,vaccinedowry to their daughters ,vaccine
cost is nothing against it.cost is nothing against it.
 It is cost effectiveIt is cost effective
Educational Program 2009
73

74. 74
Screening & Vaccination
 Pap testing and screening for HPV DNA or HPVPap testing and screening for HPV DNA or HPV
antibody are not needed before vaccination at any age.antibody are not needed before vaccination at any age.
• Benefits may be limited to protection against HPVBenefits may be limited to protection against HPV
genotypes with which they have not been infected.genotypes with which they have not been infected.
• Women infected with vaccine HPV-type and haveWomen infected with vaccine HPV-type and have
cleared the cervical infection appears to havecleared the cervical infection appears to have
similar protective effects as in HPV naïve to thesimilar protective effects as in HPV naïve to the
same vaccine HPV-type.same vaccine HPV-type.

75. 75
3
North America:
USA
Canada
Mexico
8
South America:
Brazil Bolivia
Argentina Uruguay
Peru Ecuador
Colombia Chile 26
Middle East & Africa:
Gabon Congo Kinshasa
Israel C.A.R.
Morocco Mauritius
Kenya Kuwait
Mauritania UAE
Guinea Eq. Ethiopia
Uganda Togo
Malawi Congo Brazzaville
Jordan Egypt
Cote d’Ivoire Burkina Faso
Chad Bahrain
Saudi Arabia Botswana
South Africa Cameroon
13
Asia Pacific:
Australia
Indonesia
Korea
Taiwan
Hong Kong
Singapore
New Zealand
Macau
Malaysia
Philippines
Thailand
India
Vietnam
40
Europe:
Germany Cyprus Ireland
France Czech Republic Latvia
UK Denmark Lithuania
Spain Estonia Luxembourg
Italy Finland Malta
Austria Greece Netherlands
Belgium Hungary Norway
Bulgaria Iceland Poland
Portugal Romania Slovakia
Slovenia Sweden Serbia
Montenegro Switzerland Liechtenstein
Turkey Croatia Bosnia
Russia Macedonia Belarus
Georgia
Caribbean & Central America:
Costa Rica Trinidad
Puerto Rico El Salvador
Guatemala Honduras
Curaçao Nicaragua
Bermuda Panama
Bahamas Cayman Islands
Barbados Aruba
Jamaica Dominican Republic
16
Gardasil Approvals: 156 countriesGardasil Approvals: 156 countries

76. 76
Is this vaccine is using with anotherIs this vaccine is using with another
developing country?developing country?
 Yes, this vaccine is available in 156 country.Yes, this vaccine is available in 156 country.
till date 200 million doses already usedtill date 200 million doses already used
within 9 years of time.within 9 years of time.
Educational Program 2009 76

77. 77

78. 78
ButBut
PRIMARY PREVENTIONPRIMARY PREVENTION
is most important.is most important.

79. 79
Preventing aspects-lifestyle changePreventing aspects-lifestyle change
Social change –avoid early marriagesSocial change –avoid early marriages
Multiparity_ role of family planningMultiparity_ role of family planning
Avoid multiple partnersAvoid multiple partners
Use of condom to avoid STD,and HPV diseasesUse of condom to avoid STD,and HPV diseases
Improve nutrition and personal hygieneImprove nutrition and personal hygiene
Prevents smoking ,alcoholism ,etcPrevents smoking ,alcoholism ,etc
Regular exerciseRegular exercise
Health awareness-health check upHealth awareness-health check up

80. To produce a Cancer Free Society
Screening and identification of High Risk groups
Education – Think of Cervical Cancer as an
extension of STD
Behavioral changes
Limit number of sexual partners
Delay initial age of sexual intercourse
Avoid STD – Use of Condoms/ Spermicidals;
Avoid Smoking
HPV Vaccines to be promoted at the right age

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Lets fight against cancerLets fight against cancer
……..join hands……..join hands……
……..take preventive measures……...take preventive measures…….
……..update yourself…....update yourself…..
……..take care…....take care…..

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