**3.5 Herd immunity does not exist**

Herd immunity, or the increase in protection rate of the unvaccinated population as the overall vaccination rate increases, is a well-known fact for all types of vaccines. In Sweden, even though quadrivalent HPV vaccination rates are very low, 15–44 years old unvaccinated men and women had significant decrease on the annual rate-of-change percentage [21]. Therefore, as the community vaccination rate increases, those who are not vaccinated with HPV-related vaccines will develop HPV-related diseases at a lower rate.

### **3.6 Vaccinations are not effective when done at later ages**

It was shown that HPV vaccination generates high neutralizing antibody levels when done in early childhood as well as at later ages. PATRICIA and FUTURE studies, at four age groups of 15–25, 26–35, 36–45 and 46–55 years old, shows consistent antibody levels for all of them. Even if there is not a statistical significance on vaccination of the naïve population, it is expected to be more effective. However, for all three vaccinations, EMA (European Medicine Agency) does not provide a set age limit. After considering the available data and studies, EMA decided to lift the age limit on women. However, there is a soft 25 years-old upper limit for men. This age limit is due to follow-up case series not being available yet.
