Moreover, although there is emerging evidence for herd immunity and vaccine-associated decreases in population prevalence [47] and [48], understanding of this impact on population-levels of infection is still in its infancy and data are limited to just a few sites with robust surveillance systems [49]. Nonetheless, following regulatory approval of the HPV vaccine in the United States of America, several States mandated

the use of the vaccine among young girls [50]. Concerns about mandatory HPV vaccine policy included questioning the see more role of the state in mandating an intervention with uncertain long-term efficacy and disquiet over the concept of “public health necessity” as applied to HPV50. Moreover, questions have been raised about mandating a vaccine for one sex only – i.e. only young girls (and not young boys) were required to be vaccinated in the states which passed legislation on HPV vaccine [51]. In addition to the role played by ideas, including human rights laws and standards, vaccine policies are also influenced by interests and institutions. Commercial interests driven by powerful institutions

were seen to be influential in promoting mandatory HPV vaccine policy in the State of Texas (USA) [52]. Public officials found themselves embroiled in a policy dispute between disparate advocacy Libraries groups who opposed mandates (with opponents ranging from the religiously Bafilomycin A1 nmr affiliated to more libertarian groupings) and lobbyists with links to commercial companies producing the vaccine. A political decision to mandate

the vaccine for all girls in the sixth-grade at school was particularly derided when the links between the vaccine manufacturer and senior politicians in the State already were made public [53]. It is not only powerful commercial institutions that have played a role in HPV vaccine politics. Parents, civil society groups and those representing religious viewpoints, have all at some time or another vocalized and acted to promote their interests in relation to vaccine policy. The introduction of HPV vaccine trials in India through ‘demonstration projects’ met with fierce resistance from civil society organizations. These groups were concerned about issues of “safety, efficacy and cost-effectiveness” and expressed their worries in two memoranda to the Indian Government [23]. With almost 70 civil society organizations advocating for stopping the trials, the force of pressure on the Government was such that the HPV vaccine demonstration projects were suspended and a formal enquiry was launched. In other settings, civil society groups have used State obligations under international human rights treaties to make HPV vaccine available and affordable.