Dr RG Wiseman Pinto
Human Papilloma Virus (HPV) is a DNA virus with double strands has a tropism for the squamous epithelial cells more so the basal layer.There are around 200 serotypes and molecular types of HPV. The high risk types Types 16, 18 can cause cancer of the cervix 99%, cancers of vagina, penis, scrotum, anus, oropharynx and adenocarcinoma of the cervix and also urinary bladder cancers.
The HPV produces the Oncoproteins E 5 , E6 and E 7. The infection can be diagnosed by PCR. DNA ISH (In situ hybridization) , RNA ISH P 16 is the surrogate marker detected by IHC immunohistochemistry.
The mode of transmission is by vaginal sex, oral sex, and anal sex as well as by intimate touching like fingering. by sharing sex toys and from mother to the child. By oral sex, the HPV virus is transmitted from the genital region to the mouth, oropharynx and tonsils causing head neck cancer.
Smoking and impaired immunity will help the virus to progress , and cause cancer.
Dr Harald Zur Hausen, a German virologist first demonstrated the relation between HPV serotypes 16 and 18 and cancer cervix. For this discovery he was awarded the Nobel Prize in Physiology or Medicine in 2008.
Gardasil and Cervarix
In India the Government of India has launched an immunisation drive for girls Aged 14 .Gardasil 4 which is a Quadrivalent HPV Vacvine developed against the HPV serotypes 16. 18 , 6 and 11
The HPV vaccine is given to the girls and boys before their sexual activity.In Western countries and developed countries it is given at ages of 11 to 12 years.The vaccine gives 97 % to 99 % protection against HPV. The immunity lasts for around 10 years
The HPV vaccine Gardasil was approved by US FDA in 2006.Currently recommended by WHO and being used in 150 countries. First used in 2006, Australia is the first country to give the vaccine for girls and boys.
Due to alleged reported side effects Japan withdrew the vaccine in 2013. But in 2021 Japan had restarted the HPV Vaccination Programme.
Contraindications
What are the side effects of the HPV vaccine ? They are pain , swelling. redness at the injection site. fever, dizziness, fainting , headache, fatigue, joint pain, very rarely allergy and anaphylactic shock. GB ( Guillaine Barre ) syndrome and other autoimmune diseases.
The vaccine is administered by intramuscular injection 2 to 3 doses.
Gardasil is a recombinant, non infective 4 valent vaccine. It uses the capsid protein of the HPV types 16 ,18 ,6, 11. It induces a strong immune response. The immunity lasts for 10 to 12 years.
Inspite of vaccination it must be stressed that the women must be screened after marriage with paps smears testing and HPV testing every 3 to 5 years.
AstraZeneca and Merck have a major stake in the HPV vaccine. In 2008 when the Nobel Prize was announced there was a major controversy regarding financial conflict of interest and exclusion of other key researchers. AstraZeneca which had a stake in the HPV vaccine was also the sponsor of Nobel Web and Nobel Media and has ties with the Nobel Foundation. Also one member of the Board of AstraZeneca was also on the Nobel Committee which selects the prize winners.
The risk factors for cancer of the cervix are HPV , smoking , low immunity , early onset of sexual activity below 18 years , multiple sexual partners, parity ie many children ,other sexually transmitted diseases, obesity , imbalanced diet ,oral contraceptives , and DES ( Di ethyl stilbesterol ) given to the mother during pregnancy. Family history must also be considered.
A study was conducted by Dr Anjali Naik and Dr RG Wiseman Pinto in Goa Medical College. It was a 10-year study from 2010 to 2019 involving 11.690 cancers of all sites. In this study the incidence of breast cancer was 22.75 % and cervix cancer was 8.67 %. So breast cancer is the commonest and cervix cancer is the second commonest in women in Goa.
The author at an International Conference in Yokohama. Japan in May , June 2016 ( ICC International Congress of Cytology ) had recommended 2 important points to the WHO and authorities in India . 1) To screen the women in india for the HPV serotypes so as to know the prevalence and the serotype in India.
2) To give the vaccine at a slightly later age in India as the girls in india are sexually active later as compared to the West. The modern trends may be changing.
So the take home message is inspite of being vaccinated every women must get a periodic pap smear test and HPV test done.
Pap smears are done in Goa in all government and private hospitals. HPV testing is done by the Obstretics and Gynecology Department and Microbiology Department of GMC as well as the District and Sub District hospitals in Goa.
The HPV vaccine is recently launched all over India in 2026 , though first introduced in the developed countries in 2006. Due to the high cost the vaccine was given in metro cities to the rich patients. Now the government of India is giving the vaccine free of cost.
Dr Zahra Maleki, Associate Professor of Pathology John Hopkins Baltimore has done extensive work on HPV related head neck cancers. She presented a case of a black American girl of 18 years who had HPV related head neck cancer and was not given HPV vaccine. The author discussed with Dr Maleki and concluded that if she had taken HPV vaccine it would have protected her from head neck cancer as well as cervical cancer.
(The writer is Professor of Pathology, Former HOD and Former Dean Goa University, President South Asian Academy of Cytopathology and Histopathology (SACH))
