**3.7 Smear or other HPV tests should be performed before the vaccination**

Vaccination will not protect against infections that occurred prior to it. FUTURE III study shows us that developing both HPV 16 and 18 together has a chance less than 1%. According to abnormal smear results, HSIL and cancer are only correlated with high-risk HPV types. On the other hand, LSIL is correlated with both high-risk HPV types as well as others. Hence, HPV DNA test prior to vaccination can only tell for less than 1% of women if the vaccine cannot protect against the most prevalent types 16 and 18. Studies also show that vaccinations help reduce reinfection rate for prior type 16 and/or 18 infections. On top of the infections, a randomized control study on LEEP treated cases due to HSIL, shows us that vaccinated group had a

reduced reinfection rate at 2.5% compared to 8.5% [16]. According to this data, smear or HPV DNA tests are not required prior to vaccination.

## **3.8 If a pregnancy occurs during vaccination, it should be terminated**

There are limited number of cases about uses of bivalent and quadrivalent HPV vaccination during pregnancy. Both vaccines are classified as category B due to prior data. Comparison between vaccinated and unvaccinated group did not show an increase in the infant's congenital anomaly rates. However, due to unavailability of more data, vaccination during pregnancy is not recommended. This does not mean that the vaccination is done without knowledge of the pregnancy, that it should be aborted [22].
