Cancer of the uterine cervix is the second largest cause of cancer deaths in women, and its toll is greatest in populations that lack screening programmes to detect precursor lesions. Persistent infection with 'high risk' genotypes of human papillomavirus (HPV) is necessary, although not sufficient, to cause cervical carcinoma. Therefore, HPV vaccination provides an opportunity to profoundly affect cervical cancer incidence worldwide. A recently licensed HPV subunit vaccine protects women from a high proportion of precursor lesions of cervical carcinoma and most genital warts. Here we examine the ramifications and remaining questions that surround preventive HPV vaccines.Epidemiological and laboratory studies overwhelmingly support a necessary role for persistent human papillomavirus (HPV) infection and transcription in cervical carcinogenesis 1,2 (BOX 1). Importantly, HPV infection alone is not sufficient for cervical carcinogenesis, and additional steps occur over one or two decades. HPV is probably the most common sexually transmitted disease. It is estimated that the worldwide agestandardized prevalence of current HPV infection is 10.5% (95% CI 9.9-11.0) of women; the prevalence varies about 20-fold between different regions, from 1.4% (95% CI 0.5-2.2) in Spain to , although adenocarcinomas of the cervix are more challenging to detect with this approach. Progression to cancer can usually be prevented by the ablation or surgical removal of high-grade precursor lesions (HSIL or CIN2/3). In 2005, more than 60 million Pap smears were performed in the United States, and it is estimated that such screening programmes and intervention have reduced the incidence of cervical cancer by ~80% in the United States, but at a cost of more than US$6 billion a year.Despite this success, many women do not have access to screening. This problem is most acute in disadvantaged minorities in developed nations, in cultures that do not accept the screening process and in countries that are remote and lack the resources for screening programmes. Consequently, the impact of cervical cancer is greatest in these countries; the latest global estimates (from 2002) are 493,000 new cervical cancer cases each year, and 274,000 deaths, 80% of which occur in developing countries 8 .Vaccination traditionally represents the most cost-effective approach to combat infectious disease. Two approaches to vaccination, or a combination of both, can be considered: prophylactic (preventive) and therapeutic immunization. Prophylactic vaccination of healthy individuals against the aetiological agent protects against acquisition of the disease, but confers some risk to otherwise healthy patients and requires massive programmes to vaccinate a significant fraction of the population. Comprehensive prophylactic vaccination has historically proven most successful in disease reduction. The US Food and Drug Administration (FDA) approved a preventive HPV vaccine on 8 June 2006 for the immunization of women between 9-26 years of age 9 , and a second vacci...