Flu Vaccine For Everyone: When the Science Contradicts the Science

[Skeptic Ginger]

There has been a controversy over the last decade with the US recommending flu vaccinations for everyone and mandating hospital health care workers get the vaccine as an infection control measure to protect patients. The UK (and EU I believe) still only recommend vaccination of people with specific risks for flu complications, and Canada falls somewhere in between. Maybe someone can tell us what Oz is currently recommending or I'll look it up later.

There are numerous studies demonstrating the benefits of vaccinating healthy people and of the need to vaccinate health care personnel, there are cost effectiveness studies showing employers save money by vaccinating their work forces and there are studies showing from 30-40% of pediatric deaths from influenza occur in children who had no identifiable risk factors. If that number is correct, why would protecting the 60% be peachy but the other 30-40% not be a large enough number (even considering per capita flu figures) to be worth intervening.

But along with all these studies and what seems like logical choices, (preventing the spread to patients and protecting the smaller but not zero number of healthy people who suffer severe influenza) the Cochrane Collaboration (Cochrane Reviews) have published several meta-analyses which, while finding mixed results in the studies deemed good enough for their standards, have added the caveat to these analyses that drug company funded studies dominate the peer reviewed journals and the Cochrane reviewers also suggest drug company funded studies are over-estimating the vaccine benefits. The Cochrane Review conclusions state they cannot find evidence to justify vaccinating either health care workers or people who don't have the standard influenza risk factors.

Of course, because I take a stand on one side of this controversy after having reviewed the studies and reviews over the decade, I have to be careful to consider my confirmation bias. I am bothered by the implications the vaccine manufacturers are stacking the deck.

OTOH, it makes no sense to me whatsoever that if the vaccine works at all, and I think we can say clearly it does, and with all the evidence we have that influenza is a very serious pathogen, why one would not then benefit from wider use of this vaccine?

From my perspective, when you have two discrepant data sources (lots of published research and several relevant Cochrane Reviews) it's wise to look for the reason for the discrepancy. It's not wise to assume the Reviews are superior because RCTs are the gold standard for medical research, or that the benefit only shows up because drug companies fund the studies (a lot of the studies are done in collaboration with universities and HMOs like Kaiser and Group Health, they aren't all direct drug company research). And it's not wise to ignore the potential for confirmation bias either.

So, rather than start off with all the links, they can be overwhelming, we are talking about hundreds of studies and reviews, I thought I'd just start the discussion and see what people think.

[Cuddles]

Originally Posted by Skeptic Ginger

there are studies showing from 30-40% of pediatric deaths from influenza occur in children who had no identifiable risk factors. If that number is correct, why would protecting the 60% be peachy but the other 30-40% not be a large enough number (even considering per capita flu figures) to be worth intervening.

According to WHO guidelines, being a child is a risk factor.

[casebro]

Cuddles brings up a good point. People seem to think this can be a zero risk utopian world, where we expect everything to be made perfect. But shouldn't we accept a baseline risk? "Childhood is a risk factor" seems a baseline. Same as the forgotten but true, that the number one risk factor for heart disease is age, not cholesterol level. Cholesterol is just the major CONTROLLABLE risk factor. Childhood is NOT controllable. And there is only one way to control old age.

So far as vaccines in general go, I think we have picked all the low hanging fruit. I'm thinking along the lines that study results ought to be posted as "how much longer it would add to the average life span if we all got this vaccine". I want a study that shows how much longer those with vaccination live than those without- since most of us die in our 70's of 'not infectious causes'. I guess I'm talking absolute risk, not relative, vs absolute gain ? Maybe I'll go look up the numbers- how many of us die of flu? Out of the millions that die each year?

[Dymanic]

Probably worth looking at it from a cost/benefit standpoint.

Influenza vaccine is easily the cheapest of any of the vaccines listed here:
http://www.cdc.gov/vaccines/programs...ist/index.html
And could probably be made even cheaper if uptake were consistently higher and more reliable -- especially considering that the cost of each dose administered has to absorb the cost of the enormous numbers of unused doses that end up getting destroyed at the end of each season. How many doses of vaccine could be administered for the price of one single flu-related ICU stay?

Calculating the social costs of influenza is considerably more complicated. Absenteeism has an impact on GDP, but knowing that doesn't make it easy to calculate. It's not hard to see how an untimely case of the flu in an individual holding a key position in some pivotal business or agency could propagate upward to rather large and long-lasting effects.

I don't see us ever achieving herd immunity against influenza through vaccination, especially if the efficacy/efficiency rates really are as poor as some of these studies suggest.

[Puppycow]

Here's what I'd like to know:

Although the risk of death is relatively small for healthy older children or adults, a bout of the flu is still something I would prefer to avoid.

Assuming an average person gets the vaccine every year for their whole life, how many bouts of the flu would we expect that to prevent? Even if we ignore the small risk of death or serious complications, if it prevents 10 to 20 weeks of suffering and lost productivity over a lifetime, isn't that worth it?

[Estellea]

Originally Posted by Skeptic Ginger

There has been a controversy over the last decade with the US recommending flu vaccinations for everyone and mandating hospital health care workers get the vaccine as an infection control measure to protect patients. The UK (and EU I believe) still only recommend vaccination of people with specific risks for flu complications, and Canada falls somewhere in between. Maybe someone can tell us what Oz is currently recommending or I'll look it up later.

There are numerous studies demonstrating the benefits of vaccinating healthy people and of the need to vaccinate health care personnel, there are cost effectiveness studies showing employers save money by vaccinating their work forces and there are studies showing from 30-40% of pediatric deaths from influenza occur in children who had no identifiable risk factors. If that number is correct, why would protecting the 60% be peachy but the other 30-40% not be a large enough number (even considering per capita flu figures) to be worth intervening.

But you are really looking at a snapshot of studies that have been shown to be rife with methodological problems and publication biases. The beauty of comprehensive reviews (done systematically) is that all data are considered, sifted through and results pooled.

Quote:

But along with all these studies and what seems like logical choices, (preventing the spread to patients and protecting the smaller but not zero number of healthy people who suffer severe influenza) the Cochrane Collaboration (Cochrane Reviews) have published several meta-analyses which, while finding mixed results in the studies deemed good enough for their standards, have added the caveat to these analyses that drug company funded studies dominate the peer reviewed journals and the Cochrane reviewers also suggest drug company funded studies are over-estimating the vaccine benefits. The Cochrane Review conclusions state they cannot find evidence to justify vaccinating either health care workers or people who don't have the standard influenza risk factors.

Of course, because I take a stand on one side of this controversy after having reviewed the studies and reviews over the decade, I have to be careful to consider my confirmation bias. I am bothered by the implications the vaccine manufacturers are stacking the deck.

I would highly recommend Ben Goldacre's "Bad Pharma". It is a must-read for any healthcare professional, policy-maker, regulator, academic and med student. The fact is, is that industry-funded/conducted studies are more likely to only publish positive results and those tend to show up in higher-impact journals which hold more sway than lower-tier journals where negative, (real) academic results get buried.

Quote:

OTOH, it makes no sense to me whatsoever that if the vaccine works at all, and I think we can say clearly it does, and with all the evidence we have that influenza is a very serious pathogen, why one would not then benefit from wider use of this vaccine?

Because the effectiveness is highly variable across different age and risk groups and also due to strain match. The overall effectiveness is grossly over-stated which is why, on a population basis and pooling data, the actual effectiveness is reduced. The vaccine isn't useless but benefits are simply over-stated.

Quote:

From my perspective, when you have two discrepant data sources (lots of published research and several relevant Cochrane Reviews) it's wise to look for the reason for the discrepancy. It's not wise to assume the Reviews are superior because RCTs are the gold standard for medical research, or that the benefit only shows up because drug companies fund the studies (a lot of the studies are done in collaboration with universities and HMOs like Kaiser and Group Health, they aren't all direct drug company research). And it's not wise to ignore the potential for confirmation bias either.

Jefferson does have a bit of an inflated enthusiasm for RCTs but if you look at the reviews, there are many study types included in analyses such as observational, case-control and cohort studies. RCTs aren't the end-all-be-all but should be employed more than they are. Additionally, there are a lot of dirty tricks played with regards to academic research such as ghost-writing and not allowing academics full study control for industry-sponsored research. None of these have to be declared either with our current loose regulations. I've sadly seen it myself in my own institution which is a tier-one research institute.

Quote:

So, rather than start off with all the links, they can be overwhelming, we are talking about hundreds of studies and reviews, I thought I'd just start the discussion and see what people think.

I'd like to give you a link anyway that you might find illuminating: http://www.cidrap.umn.edu/cidrap/cen...i-landing.html although there appear to be some discrepancies here too. This is also an eye-opener that we can cross-reference physician authors on favourable publications: http://www.propublica.org/series/dollars-for-docs Forgive me if this sounds patronising but I think it's great you are questioning the discrepancies in the data; it's what good sceptics do. By doing so, we are not indicting the industry as a whole, or the entire publication process or regulation but rather segments of it that need improvement and transparency to move forward with evidence-based medicine, not just giving lip-service to it.

Este

[Professor Yaffle]

In the previous thread, I hadn't really looked at the effectiveness studies and had assumed that the jab was effective in all groups, just wasn't recommended universally because of cost-effectiveness. If the cochrane is saying perhaps not in healthy young adults, that is a good starting point for me to make a decision about whether to purchase it outside of the NHS. Looking at the studies individually can give a misleading picture for a variety of reasons, as Estellea mentions above (and yes I have read Bad Pharma too...), so I am much happier to rely on a well done systematic review rather than be misled by possibly biased or poorly done studies.

If the starting point for my decision is that it may not be any use to me in terms of avoiding complications/hospitalization/death, I then look at whether it is worth my while taking it just to reduce my risk of catching the flu. Given that I have always felt pretty lousy - achy, sometimes feverish - after having the jab in the past (I was on the doctor's list as having asthma for a few years even though I had grown out of it except as part of an allergic reaction to animals, so I got it on the NHS), I have to weigh that into my calculation too and at the moment don't feel it is worth going through the negative side-effects (high risk of) in order to reduce my risk of catching the flu (low risk of: from 4% to 1% in a good matching year, and from 2% to 1% in a poor matching year).

If the cochrane conclusions change, I'll change my mind too - I'm not set against the jab. the personal cost benefit analysis is just a little too flimsy for me at the moment.

[ServiceSoon]

Have you seen Evidence grows for narcolepsy link to GSK swine flu shot yet? Perhaps that's what triggered your post.

Personally, I can not recall the last time that I contracted the flu, therefore I have never taken the flu shot. I guess the explanation is that I have a rocking immune system. Just like you, I have to be careful about my confirmation bias.

[Skeptic Ginger]

While I will get to individual posts I want to reiterate a point. It's not about study reliability unless you want to claim that the vaccine doesn't work at all, in which case I don't think that's a supportable claim, and/or unless you want to say people with no pre-existing health problems will not benefit from protection from influenza.

Given that reality, one has to look for the reason the meta-analyses aren't showing benefits. You can't just assume it's magical RCT gold with unquestionable conclusions.

@Este I'm familiar with Goldacre's work. I also recommend you (and others) read "Snake Oil Science" which while it talks mostly about bad science supporting alternative medicine it offers some eye openers about looking critically at all medical research, no exceptions.

So before anyone decides the 'gold standard' Cochrane Reviews mean persons who are otherwise healthy won't benefit from flu vaccinations, one needs to explain why the results make no sense.

[fuelair]

Regarding Estellea's post, I also suggest if you are really interested in keeping up with honest (and oft times funny) reporting on pharma stuff you should be checking Derek Lowe"s In the Pipeline blog: http://pipeline.corante.com/archives...ont_work_with/

Among many things (bad drug company policies and management, the low hanging fruit problem, fraud in science, IP theft +++++) you should be able to find info on pretty much anything you are curious about in the field from a pro.

Plus, you can ask questions and get responses!!!

[r-j]

Originally Posted by ServiceSoon

Have you seen Evidence grows for narcolepsy link to GSK swine flu shot yet?

I wish I did not know about that.

[Skeptic Ginger]

Here's an example of the results not making sense: Influenza vaccination for healthcare workers who work with the elderly ([Cochrane] Review)

Quote:

Plain Language Summary

Influenza vaccination for healthcare workers who work with the elderly

There are no accurate data on rates of laboratory-proven influenza in healthcare workers. The three studies in the first publication of this review and the two new studies we identified in this update are all at high risk of bias. The studies found that vaccinating healthcare workers who look after the elderly in long-term care facilities did not show any effect on the specific outcomes of interest, namely laboratory-proven influenza, pneumonia or deaths from pneumonia. An effect was shown for outcomes with a non-specific relationship to influenza, namely influenza-like illness (which includes many other viruses and bacteria than influenza), GP consultations for influenza-like illness, hospital admissions and the overall mortality of the elderly (winter influenza is responsible for less than 10% of the deaths of individuals over 60 and overall mortality thus reflects many other causes).

They start by saying none of the studies meet Review standards. I'm not sure you'd get an argument there. We don't have many RCTs where everyone with an ILI gets a viral culture.

That will change in the next couple years because in office flu screens are now inexpensive and more readily available and more widely being used.

They note the studies are at "high risk of bias". That doesn't mean bias was found, only that methodology doesn't meet Review standards. If you look at pages 7,8 you'll see they are not referring to bias found, rather they are referring to holes in the studies, missing data and "other" being large contributors to potential bias. Page 9 describes "other".

Quote:

1. Selection bias: the total number of long-term care hospitals in West and Central Scotland is not stated. There were inconsistencies in outcome gradients (see Table 1). In the population under observation, Potter 1997 reported 216 cases of suspected viral illness, 64 cases of influenza-like illness, 55 cases of pneumonia, 72 deaths from pneumonia and 148 deaths from all causes; in the sub-population of both vaccinated staff and patients, Potter 1997 reported 24 cases of suspected viral illness, two cases of influenza-like illness, seven cases of pneumonia, 10 deaths from pneumonia and 25 deaths from all causes. As these gradients are not plausible (one would expect a greater proportion of cases of influenza-like illness to be caused by influenza during a period of high viral activity), the effect on allcause mortality is likely to reflect a selection bias rather than a real effect of vaccination.

Again, you won't see a lot of push back against these problems being identified.

But the real problem is they did find a benefit in reducing multiple outcome measures but no proof when flu cases were documented by culture. IOW health care worker flu vaccinations did show a reduced morbidity and mortality in the elderly they were caring for, but proof that was a direct effect is lacking.

That leads to a couple possibilities:

Either the vaccine prevented other illnesses: highly unlikely.
Or the effects didn't exist and were caused by some study bias: It's possible, but not clear here that's what the reviewers think was going on.
Or the cultures failed to detect all the flu cases: This is a real possibility.

You can't rule either possibility out at this point.

They end with a weak recommendation, not actually condemning the practice of health care worker vaccinations:

Quote:

We conclude that there is no evidence that only vaccinating healthcare workers prevents laboratory-proven influenza, pneumonia, and death from pneumonia in elderly residents in long-term care facilities

IOW, there's not enough evidence. They are not saying there is enough evidence and it supports the conclusion the vaccinations have no effect.

This is an important point because just saying we don't have the evidence we need yet but the hypothesis is sound, is different from saying the hypothesis has been disproved.

But let me take that even further. This review looked at one variable: Flu vaccine was offered to staff or flu vaccine was not offered to staff. The studies did not look at a group of highly vaccinated health care workers vs a group with a low rate of vaccine uptake. It's jumping the gun to conclude no benefit was shown because culture positive evidence was lacking when you don't even have good control over the study variable and ignore the evidence a benefit was possibly being detected.

And this is one of the problems with taking Cochrane Reviews as definitive results. Many of the conclusions, including this one, are, 'there isn't enough evidence', not 'there is evidence against'. We know that. There isn't enough evidence for a lot of things we do in medicine. When that happens you have to decide, is there enough evidence and low enough risk to continue the practice until more evidence is obtained? Or is the intervention so risky we should wait? When it comes to public investment such as NHS coverage of the vaccinations, that decision has to be made with consideration of where those limited resources might be better spent. When it comes to the individual, it's risk vs benefit for the individual. An employer would look at the cost of vaccine vs time loss. A hospital or clinic would be looking at the infection control benefit vs where those resources (vaccine costs) might be better spent.


There's more I will post. This stuff takes a lot of time to carefully evaluate and discuss.

[Skeptic Ginger]

Originally Posted by r-j

I wish I did not know about that.

Don't take a Yahoo news report as scientific evidence. One brand of vaccine is currently limited to kids over age 9 in the US and I believe is not being used in the EU, the risk has not been confirmed and, no evidence has been found that any other brand is involved.

[r-j]

I tend to have more faith in Reuters (http://www.reuters.com/article/2013/...90L07H20130122) reporting than somebody on the internet who doesn't know anymore than I do about something.

http://www.webmd.com/cold-and-flu/fe...u-vaccine-safe

It's speaking to the topic. How do you know who to trust when there are conflicting experts saying things?

[Estellea]

Originally Posted by Skeptic Ginger

Don't take a Yahoo news report as scientific evidence. One brand of vaccine is currently limited to kids over age 9 in the US and I believe is not being used in the EU, the risk has not been confirmed and, no evidence has been found that any other brand is involved.

I hope to answer your other response by tonight but wanted to address this straightaway. R-J and Service Soon are correct and you can read the report yourself from the EMA about Pandemrix.

Este

[Skeptic Ginger]

Originally Posted by r-j

I tend to have more faith in Reuters (http://www.reuters.com/article/2013/...90L07H20130122) reporting than somebody on the internet who doesn't know anymore than I do about something.

http://www.webmd.com/cold-and-flu/fe...u-vaccine-safe

It's speaking to the topic. How do you know who to trust when there are conflicting experts saying things?

You look at the actual science directly when you can. Unfortunately that isn't always practical so you do have to weigh the reliability of the sources.

In this case we, as in the medical community, do look to Cochrane Reviews with high regard. But likewise the ACIP does an incredibly thorough review of the evidence before making vaccine recommendations. They aren't exactly industry dupes. In addition, two organizations have thoroughly evaluated the evidence re vaccinating health care workers, APIC and The Joint Commission (formerly JCAHO). They also don't make recommendations lightly and they are well aware of the Cochrane Reviews.

TJC: Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies from Research and Practice

APIC Position Paper: Influenza Vaccination Should Be a Condition of Employment for Healthcare Personnel, Unless Medically Contraindicated

ACIP flu vaccine recommendations

Quote:

Among healthy younger adults, illness caused by seasonal influenza is typically not severe and rarely results in hospitalization, compared with children aged <5 years, adults aged ≥65 years, pregnant women, or persons with chronic medical conditions. However, illness burden among healthy adults aged 19--49 years is an important cause of outpatient medical visits and worker absenteeism. The impact of influenza varies considerably by season, making estimates of the attack rate in healthy younger adults difficult. In most studies, attack rates have varied from 2% to 10% annually, and influenza has been estimated to cause 0.6--2.5 workdays lost per illness (76--80). In one economic analysis, the average annual burden of seasonal influenza among adults aged 18--49 years who did not have a medical condition that conferred a higher risk for influenza complications was estimated to include approximately 5 million illnesses, 2.4 million outpatient visits, 32,000 hospitalizations, and 680 deaths (78).

The ACIP notes:

Quote:

Randomized controlled trials that measure laboratory-confirmed influenza virus infections as the outcome are the most persuasive evidence of vaccine efficacy, but such trials cannot be conducted ethically among groups recommended to receive vaccine annually....

...The majority of healthy children and adults have high titers of antibody after vaccination (139,142)....

The immunogenicity, efficacy, and effectiveness of TIV (flu jabs) in healthy children and adults is well documented, as are adverse events from the vaccine with the sources cited in the ACIP guideline. The Cochrane Reviews are cited throughout the guideline, it's not like they didn't look at them.

It's clear from the main authors on the Cochrane Reviews of flu vaccine in healthy children and adults (Jefferson T, Rivetti A, Harnden A, et al.) they have a very clear opinion of their own on this matter. Their condemnation of the research in healthy children progresses (08, 10, & finally 2012) with the criticism expanded in the 2012 abstract.

Quote:

AUTHORS' CONCLUSIONS:
Influenza vaccines are efficacious in preventing cases of influenza in children older than two years of age, but little evidence is available for children younger than two years of age. There was a difference between vaccine efficacy and effectiveness, partly due to differing datasets, settings and viral circulation patterns. No safety comparisons could be carried out, emphasising the need for standardisation of methods and presentation of vaccine safety data in future studies. In specific cases, influenza vaccines were associated with serious harms such as narcolepsy and febrile convulsions. It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months of age in the USA, Canada, parts of Europe and Australia. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes, and directly comparing vaccine types are urgently required. The degree of scrutiny needed to identify all global cases of potential harms is beyond the resources of this review. This review includes trials funded by industry. An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry-funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favourable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in the light of this finding.

It's like reading a progression of the authors getting angrier and angrier. The claim of industry manipulation of conclusions is particularly worrisome.

But I read all that and still have 3 separate agencies, public health, a national infection control organization, and the agency responsible to accredit hospitals and health care organizations, all looking at those same reviews as well as the research itself and coming to the opposite conclusion.

I fail to see why the Cochrane Reviews should be given the status of superior argument from authority. And whose to say the reviewers themselves aren't subject to confirmation bias? These same reviewers looked at the flu vaccine research in healthy adults and children for the last decade. I'd love to see a review of the same studies done by some other reviewers.

Look at their conclusion in the 07 review of vaccine in healthy adults:

Quote:

AUTHORS' CONCLUSIONS:
Influenza vaccines are effective in reducing cases of influenza, especially when the content predicts accurately circulating types and circulation is high. However, they are less effective in reducing cases of influenza-like illness and have a modest impact on working days lost. There is insufficient evidence to assess their impact on complications. Whole-virion monovalent vaccines may perform best in a pandemic.

The evidence is the vaccine works but only have a modest impact on ILIs altogether and lost workdays? Well d'uh! People call in sick for all kinds of reasons and ILIs include many illnesses not caused by influenza. What are these reviewers expecting to find? Flu vaccine prevents all ILIs and time loss? That's nuts.

I've looked at the summaries of 4 or 5 of these reviews just now and they all find some benefit from flu vaccines. They consistently find inadequate RCTs have been done. That's true for 80% of Cochrane Reviews give or take. And with all that, the authors' conclusions are worded in ways that negatively reflect vaccinating healthy children and adults.

I repeat my question. The vaccine works, healthy adults and children should benefit from avoiding the flu. Why are these same reviewers again and again concluding those two things aren't true?

Explain to me why a vaccine against the flu in a healthy child or adult is not going to do anything measurable? I.e. explain the Cochrane Review results in some way that makes sense besides simply, the studies have not been done? Perfect RCTs have not been done for the majority of medical interventions we use. That doesn't mean evidence for those interventions is lacking, it just means perfect evidence is.

I would be interested in other country's similar agency's discussions (not a summary but the full rationale) of their flu vaccine recommendations for healthy children and adults and for health care workers as an infection control measure. I'll look for them if no one familiar posts links.

[Skeptic Ginger]

Originally Posted by Estellea

I hope to answer your other response by tonight but wanted to address this straightaway. R-J and Service Soon are correct and you can read the report yourself from the EMA about Pandemrix.

Este

I didn't say it wasn't correct. I said the vaccine in question was pulled. The news reports makes it sound like the risk turned up with all flu vaccine and that it was conclusively true. Neither of those are correct. The side effect was suspected and the vaccine pulled as soon as it was.

There have been things like this over the years and not all of them turn out to be true causal associations when all the data is in. But drug companies rightly so pull drugs when there is a possible link until the link is rulled out.

You seem to think I don't recognize vaccine risks. I do. And I have no doubt that influenza disease risks outweigh those vaccine risks. For all the kids who developed narcolepsy, there are more kids who died from flu without identified risk factors. No one is saying vaccine adverse events never happen. It's always risk vs benefit when prescribing a vaccine. I'm a very conservative prescriber when it comes to pharmaceuticals. And like I said in the other thread, I didn't dismiss these Cochrane Reviews when they were published. You seem to think because I agree with the ACIP, APIC and TJC that I'm somehow victim of confirmation bias while people who take the brief summary of the Cochrane Reviews are not.

Care to at least have this discussion on more neutral grounds?

[pgwenthold]

Originally Posted by Skeptic Ginger

It's clear from the main authors on the Cochrane Reviews of flu vaccine in healthy children and adults (Jefferson T, Rivetti A, Harnden A, et al.) they have a very clear opinion of their own on this matter.

Well, Jefferson is pretty much, by his own admission, an outlier in his views of the field. Of course, he pitches it as a Brave Maverick Who Alone Knows the Truth, while everyone else are just a bunch of dupes.

[Skeptic Ginger]

Originally Posted by pgwenthold

Well, Jefferson is pretty much, by his own admission, an outlier in his views of the field. Of course, he pitches it as a Brave Maverick Who Alone Knows the Truth, while everyone else are just a bunch of dupes.

That's interesting. Do you have any sources with more about the person?

[Puppycow]

Professor Y: I get the achy thing too from the jab but it's hardly comparable to catching the flu IMHO.
You cited 2-4% as the odds of getting the flu without a vaccine. Are you sure about those numbers? This link says 5-20% for the US. I realize it might be different in the UK.

http://www.m.webmd.com/cold-and-flu/flu-statistics

[Skeptic Ginger]

Don't know if this source on Dr Jefferson is correct but it's worth discussing. To me it's a no brainer that all ILIs are not influenza. I always go to the culture samples to estimate influenza cases. I thought everyone in the flu field knew that. The people I work with certainly do.

So here's one of Jefferson's complaints:

Quote:

To illustrate, Jefferson points to Flu Trends (www.google.org/flutrends), a site that estimates flu incidence around the world based on the number of flu-related search queries in each region. “Users of Flu Trends think they are following the spread of influenza,” he notes, “while in reality, the site depicts the spread of influenza-like illness.”

Virologist Kennedy Shortridge, PhD, agrees. “There are a number of infectious agents that can mimic flu,” says Shortridge, a professor emeritus at the University of Hong Kong and a pioneer in studying the origin of influenza. “In many cases, no laboratory diagnosis of influenza is made.”

To find out how many cases of influenza-like illness are actually influenza A or B, scientists would need to take a random sample of people diagnosed with influenza-like illness, and then test them for every possible causal agent and illness. The formal studies are few, but Jefferson has completed calculations based on data from trials for vaccines, and he estimates that, on average, only about 7 percent of those with influenza-like illness actually have influenza.

“The CDC and the media portray influenza as a deadly threat,” he says. “But the data suggest that seasonal influenza is a relatively rare and benign condition, with an incidence not exceeding 1 percent in the general population during autumn and winter months.”

Talk about confirmation bias, sheesh. The bolded part is done in the US from October to March every year and has been done for more than 2 decades! So I don't know if this guy is unaware of that or what?

The current last 3 week average shows sampled ILIs range by region from 23% to 54% influenza by culture!

The US PHDs have been doing this analysis for years. No one guesses, that I know of anyway. And the CDC has an extensive discussion in peer reviewed publications how they estimate influenza burden. They don't just guess, they use multiple checks and balances for their model. Culture positive pediatric deaths from flu have been reportable in the US since 2004.

In 2009-10 flu season some of the most intensive worldwide culturing of flu virus was undertaken monitoring for the H1N1 pandemic strain. WHO had weekly reports on the spread of the virus. They never once used ILIs as the number they were reporting. They only used documented positive cultures from reliable labs that were sub-typed as new variant 2009 H1N1 strain.

So right away, Peterson has a strong confirmation bias that the world's PHDs overreact to flu and flu is not the big deal it is claimed to be. That's mind boggling and an eye opener to me since, as Este correctly points out, the Cochrane Reviews are supposed to be such clean evaluations.

[Skeptic Ginger]

More from the above link of Jefferson's beliefs:

Quote:

On average, says Jefferson, perhaps one adult out of 100 vaccinated will get influenza symptoms compared with two out of 100 in the unvaccinated group.

Since he doesn't believe 30% of ILIs in peak flu season (culture confirmed) are really flu, how did he arrive at this number?

Quote:

Jefferson also points out that advisers on government vaccine committees vested with product approval have suspect ties to the manufacturers. With many of pharma’s most profitable drugs coming off patent in recent years, new vaccines, including influenza vaccines, have taken on an added luster. Experts predict that the seasonal influenza-vaccine market will grow to a $4 billion a year industry by 2015.

Despite all this, Doshi believes that a concern for the public’s well-being is what motivates most health officials.

I'm with 'Doshi' here. I work with these people. And, I've heard this argument before from the anti-vaxers because pharmaceutical reps are on the ACIP board. They belong there because they are experts on vaccine production issues, something that is critical to the ACIP recommendations. The ACIP gives a full accounting of their decision making process. It's transparent and published including a thorough discussion of the rationale for the final recommendations. If there was undue influence it would be visible.

Quote:

Jefferson doesn’t buy this argument: “Vaccine policies are made on the basis of personal belief. Once the policies are made, those who made them [selectively] publish the evidence to support their point of view. They keep justifying their policy on the basis of studies done by pharmaceutical companies, and they are unwilling to reexamine their decisions and reevaluate the policies.”

Or, we might be able to say the same thing about his position. He wouldn't be the first science 'maverick' to refuse to give up his pet hypothesis as the evidence accumulated against it.


So, I'm off to find some reviews that don't rely on drug company funding and don't include possible bias from Peterson to see if they corroborate or contradict the CR findings. In the end, I'm convinced the evidence will resolve the controversy.

[Estellea]

Originally Posted by Skeptic Ginger

I didn't say it wasn't correct. I said the vaccine in question was pulled. The news reports makes it sound like the risk turned up with all flu vaccine and that it was conclusively true. Neither of those are correct. The side effect was suspected and the vaccine pulled as soon as it was.

It appears to me that you did in fact have a knee-jerk reaction to a report of an adverse event.

Originally Posted by Skeptic Ginger

Don't take a Yahoo news report as scientific evidence. One brand of vaccine is currently limited to kids over age 9 in the US and I believe is not being used in the EU, the risk has not been confirmed and, no evidence has been found that any other brand is involved.

The news report was quite accurate and specified GSK's Pandemrix. The link I provided you identifies the association as being rather strong so yes, it is factual until better evidence overturns it.

Quote:

There have been things like this over the years and not all of them turn out to be true causal associations when all the data is in. But drug companies rightly so pull drugs when there is a possible link until the link is rulled out.

Of course but it appears as though you are being defensive about Pandemrix's association with a profound risk of narcolepsy without knowing the facts and dismissing a news story that was actually quite accurate, not to mention numerous other sources that are available which could have verified it.

Quote:

You seem to think I don't recognize vaccine risks. I do. And I have no doubt that influenza disease risks outweigh those vaccine risks. For all the kids who developed narcolepsy, there are more kids who died from flu without identified risk factors. No one is saying vaccine adverse events never happen. It's always risk vs benefit when prescribing a vaccine. I'm a very conservative prescriber when it comes to pharmaceuticals. And like I said in the other thread, I didn't dismiss these Cochrane Reviews when they were published. You seem to think because I agree with the ACIP, APIC and TJC that I'm somehow victim of confirmation bias while people who take the brief summary of the Cochrane Reviews are not.

That's a strawman. No one mentioned risk v. benefit, just asked about the report regarding Pandemrix and narcolepsy. As for confirmation bias though, I'll address the discrepancy between the ACIP's recommendations and the evidence.

Este

[Skeptic Ginger]

Originally Posted by Estellea

It appears to me that you did in fact have a knee-jerk reaction to a report of an adverse event.

The news report was quite accurate and specified GSK's Pandemrix. The link I provided you identifies the association as being rather strong so yes, it is factual until better evidence overturns it.


Of course but it appears as though you are being defensive about Pandemrix's association with a profound risk of narcolepsy without knowing the facts and dismissing a news story that was actually quite accurate, not to mention numerous other sources that are available which could have verified it.

That's a strawman. No one mentioned risk v. benefit, just asked about the report regarding Pandemrix and narcolepsy. As for confirmation bias though, I'll address the discrepancy between the ACIP's recommendations and the evidence.

Este

So no neutral ground then, check.

[Skeptic Ginger]

In 2009 our friend Dr Mark Crislip from Science Based Medicine weighed in on the Cochrane Review controversy: Flu Vaccine Efficacy. His readers were bringing up Jefferson's CR work.

After an extensive discussion with lots of citations including at least one CR that supports using flu vaccine Dr C concludes:

Quote:

My army is the vaccine and the data used to support it. You can conclude that neither the vaccine nor the data is perfect, and decide the vaccine is not useful.
Or you can look at the preponderance of data, with all the flaws, nuance, subtleties and qualifiers, and conclude the flu vaccine is of benefit. The vaccine decreases the probability of morbidity and mortality. It is a good thing.

I'll take a closer look at his citations later. In the meantime you can read for yourself what the good doctor at SBM, whose specialty is infectious disease, had to say.

[ectoplasm]

Originally Posted by Skeptic Ginger

In 2009 our friend Dr Mark Crislip from Science Based Medicine weighed in on the Cochrane Review controversy: Flu Vaccine Efficacy. His readers were bringing up Jefferson's CR work.

After an extensive discussion with lots of citations including at least one CR that supports using flu vaccine Dr C concludes:

I'll take a closer look at his citations later. In the meantime you can read for yourself what the good doctor at SBM, whose specialty is infectious disease, had to say.

A month later Dr. Crislip had another screed about flu vaccination, responding to an Atlantic article that referenced Dr. Jefferson's work.

SBM

[Skeptic Ginger]

Originally Posted by ectoplasm

A month later Dr. Crislip had another screed about flu vaccination, responding to an Atlantic article that referenced Dr. Jefferson's work.

SBM

Thanks for the added source.

It's hard when one has to ask, am I just confirming my bias, or have I really looked at this and continue to believe what I initially did? It's so easy in this forum to latch on to this or that evidence and assert another forum member is simply affected by confirmation bias because they aren't coming to the same conclusion as you are.

I know about confirmation bias. And I also know I've spent hours with an open mind looking into this issue. I haven't dismissed the CRs with a hand wave.

So far I still think the evidence favors flu vaccine for everyone. And so far in this thread I've found out something I didn't know, that the lead investigator in the Cochrane Reviews has a very strong opinion of his own that could mean the confirmation bias is his.

I'm not done looking at the most recent evidence in this controversy.

[Skeptic Ginger]

From the second SBM link cited by ectoplasm:

Quote:

The Atlantic recently published an article called “Does the Vaccine Matter?.” The quick answer is “yes”. If you want to know more, keep reading. They concluded, based on a narrow interpretation of a small subset of the data, that vaccines probably do not matter. The tone suggests that the vaccine is a vast boondoggle perpetuated on the American people by frightened doctors and greedy pharmaceutical companies. At least that is my take on the article, your mileage may vary. Lets look at that article, and its review of the influenza vaccine, and see whatthe authors say, how they say it, and, perhaps more importantly, what they don’t say.

(bolding here is mine)

The following is fascinating because it addresses the typical anti-vaxer. And I'm not saying anyone who finds the CR credible is an anti-vaxer. Of course they are not. More than a few well informed medical providers were concerned about the CR results.

Quote:

Unfortunately, I do not have a good story to tell with protagonists and antagonists and lone voices protesting the evil medical industrial complex. I don’t have a morality tale to tell, with good guys and bad guys. I have the medical literature, with its numbers and uncertainties and nuance. I also have patients I have to treat and have to apply the medical literature to as best I can.

That says so much.

As does this:

Quote:

There is a logical fallacy called Argue By Demanding Impossible Perfection.

I've excerpted this, please see the whole discussion and don't accuse me of cherry picking for my edits:

Quote:

Watch as you read the article as the authors bounce from swine flu to seasonal flu to treatment to death to prevention and often fail to be precise as to what they are referring to....

Originally Posted by The Atlantic Article

But what if everything we think we know about fighting influenza is wrong? What if flu vaccines do not protect people from dying–particularly the elderly, who account for 90 percent of deaths from seasonal flu?

What if the 14,400 plus influenza vaccine articles on Pubmed are wrong, all the biology and virology and pharmacology and clinical trials about influenza are wrong? What if every brick in the wall was an illusion and the edifice of flu treatment is wrong. What if a few brave souls can see the real truth. I look forward to a review of the 50 years of influenza research in all its complexity. It’s a huge literature, with multiple lines of evidence all converging on the conclusion that vaccines and antivirals are effective against influenza. Because I would hate to make decisions based on the opinions of a few people reading a narrow sampling of the literature.
And which is it? Is EVERYTHING wrong? Everything? Or the narrow issue of mortality prevention....

Isn't this exactly the pattern we see with CTers and Dr Behe's intelligent design and climate change deniers a dozen other woo believers? But here is the same "I see it, no one else does" except the source is supposed to be reliable. Dr Behe is a qualified researcher who should be a reliable source. Some of the climate change deniers are legitimate scientists.

Yes, once in a rare while the 'maverick' turns out to be right. Evolution, plate tectonics, Dr Snow's cholera epidemiology, the midwives of the 1800s hand washing (who deserve Dr Semmelweis' credit ) and more recently, the H-Pylori researchers, turn out to be right. But these mavericks have one thing in common, the evidence supporting their hypotheses got stronger and stronger. You cannot say that when it comes to Tom Peterson's Cochrane Reviews.


This is why I started this thread. When we see the gold standard (CRs) do we assume it is not affected by the same confirmation biases as we must consider for every other medical research paper? Shouldn't we evaluate CRs with the same level of critical thinking as we apply to any medical research?

I'm more confirmation biased than ever now. And I thank Este for challenging me on this matter.

[Skeptic Ginger]

Color me wondering if Jefferson is objective:

YouTube Video This video is not hosted by the JREF. The JREF can not be held responsible for the suitability or legality of this material. By clicking the link below you agree to view content from an external website.

I AGREE

Find me a medical researcher consensus that agrees with him, or even a meta-analysis that corroborates his findings.

[Estellea]

Originally Posted by Skeptic Ginger

You look at the actual science directly when you can. Unfortunately that isn't always practical so you do have to weigh the reliability of the sources.

In this case we, as in the medical community, do look to Cochrane Reviews with high regard. But likewise the ACIP does an incredibly thorough review of the evidence before making vaccine recommendations. They aren't exactly industry dupes. In addition, two organizations have thoroughly evaluated the evidence re vaccinating health care workers, APIC and The Joint Commission (formerly JCAHO). They also don't make recommendations lightly and they are well aware of the Cochrane Reviews.

TJC: Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies from Research and Practice

APIC Position Paper: Influenza Vaccination Should Be a Condition of Employment for Healthcare Personnel, Unless Medically Contraindicated

I wonder if you have looked at any of the studies that went into writing these recommendations. I pulled four from the monograph introduction per your first link that related to absolute claims: 2, 8, 11 and 17. Only one was relevant (2) and of the rest, one was not related to healthcare workers at all, another was a previous CDC recommendation and the third was a position paper. While I still hold the opinion that healthcare workers should be vaccinated (along with employing physical mechanisms), policy language is grossly exaggerated and I would like to see that refect the actual evidence.

Quote:

The ACIP notes:

Quote:

Randomized controlled trials that measure laboratory-confirmed influenza virus infections as the outcome are the most persuasive evidence of vaccine efficacy, but such trials cannot be conducted ethically among groups recommended to receive vaccine annually....

...The majority of healthy children and adults have high titers of antibody after vaccination (139,142)....

The immunogenicity, efficacy, and effectiveness of TIV (flu jabs) in healthy children and adults is well documented, as are adverse events from the vaccine with the sources cited in the ACIP guideline. The Cochrane Reviews are cited throughout the guideline, it's not like they didn't look at them.

I wonder too if you read those cites (139 and 142) used to support this recommendation. One is a small efficacy study and the other is nothing more than a study using immunogenicity as an endpoint. Yes they cite the Cochrane reviews but they cherry-pick and give the appearance that they are supportive. Something which you have already noticed criticised by the review authors.

Quote:

It's clear from the main authors on the Cochrane Reviews of flu vaccine in healthy children and adults (Jefferson T, Rivetti A, Harnden A, et al.) they have a very clear opinion of their own on this matter. Their condemnation of the research in healthy children progresses (08, 10, & finally 2012) with the criticism expanded in the 2012 abstract.It's like reading a progression of the authors getting angrier and angrier. The claim of industry manipulation of conclusions is particularly worrisome.

Have you read Vaccines for Influenza in Healthy Children? There is pretty thin gruel to make this recommendation given the extraordinary paucity in the data regarding children between the ages of 6 months-2 years old. And what evidence there is, they are either just immunogenicity endpoints or the pooled data demonstrate no difference between placebo and vaccine for the prevention of influenza in this age group.

Quote:

But I read all that and still have 3 separate agencies, public health, a national infection control organization, and the agency responsible to accredit hospitals and health care organizations, all looking at those same reviews as well as the research itself and coming to the opposite conclusion.

Sure if you want to merely appeal to authority and popularity. Even the recent CIDRAP report I linked to earlier criticised the Cochrane group for utilising studies which would ultimately over-estimate flu vaccine effectiveness in the elderly. They also had this to say about vaccine effectiveness in children less than 2 years old:

Quote:

We identified five studies that specifically reported
vaccine efficacy or effectiveness data for TIV among
children 2 years of the age or younger. One of the
TIV studies is an RCT that reported vaccine efficacy
over a 2-year period with a good match between the
vaccine and circulating strain each year. During the first
year, vaccine efficacy was 66%, and in the following
year it was -7%.48 Similar results were reported in the
four effectiveness studies that provided data for this
age-group. These studies included 7 years of data;
for 4 years, vaccine effectiveness was not significant
and ranged from -42% to 66%.49-52 Given these
inconsistent findings, the efficacy and effectiveness of
influenza vaccines in children younger than 2 years of
age cannot be adequately characterized.

The CIDRAP report also had many interesting things to say about ACIP recommendations regarding influenza vaccine. Are they too biased and agendised? Funnily, the ACIP is adopting the Cochrane Collaborations grading system for assessing study limitations.

Quote:

I fail to see why the Cochrane Reviews should be given the status of superior argument from authority.[/b] And whose to say the reviewers themselves aren't subject to confirmation bias? These same reviewers looked at the flu vaccine research in healthy adults and children for the last decade. I'd love to see a review of the same studies done by some other reviewers.

You only fail to see it because you don't like the results. The CIDRAP meta-analysis is a different group and they drew comparable conclusions. While they weren't as openly critical of ACIP recommendations, they didn't pull any punches defining ACIPs flu vaccine recommendations as not based in science but rather opinion.

Quote:

I've looked at the summaries of 4 or 5 of these reviews just now and they all find some benefit from flu vaccines. They consistently find inadequate RCTs have been done. That's true for 80% of Cochrane Reviews give or take. And with all that, the authors' conclusions are worded in ways that negatively reflect vaccinating healthy children and adults.

I repeat my question. The vaccine works, healthy adults and children should benefit from avoiding the flu. Why are these same reviewers again and again concluding those two things aren't true?

They aren't the only ones finding that. The vaccine doesn't work as well as you think it does and a great deal of the research demonstrating effectiveness is very dodgy. These observations shake out when they are banged together. I don't see what is so hard to understand about this aside from confirmation bias.

Quote:

Explain to me why a vaccine against the flu in a healthy child or adult is not going to do anything measurable? I.e. explain the Cochrane Review results in some way that makes sense besides simply, the studies have not been done? Perfect RCTs have not been done for the majority of medical interventions we use. That doesn't mean evidence for those interventions is lacking, it just means perfect evidence is.

There isn't a demand for perfect evidence but rather better evidence. The quality of evidence does matter though. You appear to be making an argument from antiquity i.e. "that's the way we've always done it." Well no, times are changing and empirical knowledge alone doesn't cut it any longer.

Este

[kellyb]

Treading lightly here.
I deeply respect and admire the spirit of this thread, where everyone is encouraged to try to look into their own propensity for confirmation bias, other biases, and even further - to try to see potential/probable biases in sources they trust, like Cochrane authors and ACIP members.

My thoughts are sort of all over the place on this, so I'm going to try to hone in on just one or two things.

Disclosure of my current bias potential/probability: I am email friendly with some MDs in developing countries who are very angry with and suspicious of the WHO and CDC.

Anyway, from the OP:

Originally Posted by SG

OTOH, it makes no sense to me whatsoever that if the vaccine works at all, and I think we can say clearly it does, and with all the evidence we have that influenza is a very serious pathogen, why one would not then benefit from wider use of this vaccine?

My question is: is this a good use of finite healthcare resources? I mean, we don't have collective universal HC in the US, and won't in the foreseeable future as far as I can tell, but most of the developed world does. Maybe there's a good reason that most developed countries think it's a poor use of finite resources?

In the US, it's like we pretend that HC resources are infinite when it comes to vaccines, and (sorry to be vague) I know for a fact (in an anecdotal way) that pharma companies are banking on that, and they're banking on it spilling over into WHO recommendations.

I do NOT believe the folks at the WHO are corrupt, pharma shills, or anything like that. I don't think ACIP members are, either. But there IS a thing that happens where pharma funds the snot out of researchers who are genuinely enthusiastic about their most lucrative products. And then they have these huge annual conventions, like this:
http://www.preventinfluenza.org/
and this:
http://www.clocate.com/conference/Th...es-2012/14970/

...where those super-funded, thus super-published, cherry-picked for their genuine enthusiasm researchers become the opinion leaders. And I find the way it all works problematic.

Back to flu: "we" still don't understand its epidemiology, etc well at all. When the dreaded pandemic actually hit in 2009, the pandemic strain knocked out the deadlier, older H1N1. The pandemic virus actually saved lives! And nobody talks about this! Maybe almost nobody even notices.
And that's not so weird when you watch how policy/research/expert symposiums work.

Maurice Hilleman, who I think was a highly moral person and a genius, to boot, was not invited to the influenza summits. But he had a "bad" opinion on flu in the policy climate. (the fact that he CREATED the flu vax could be ignored)

http://cmbi.bjmu.edu.cn/news/report/2005/flu/78.pdf

Quote:

The H5N1chicken influenza threat may be more perceived
than real since, short of reassortment with a human virus,
zoonotic infections are of highly limited progression even
from the primary person to a second person.

I'm scared of pandemic viruses. But I'm really skeptical of the idea that universal vaccination with a vaccine that often doesn't work, and very often doesn't work for the most at-risk groups, is a good use of healthcare resources that actually are finite even in the US.

[Estellea]

Originally Posted by Skeptic Ginger

More from the above link of Jefferson's beliefs:Since he doesn't believe 30% of ILIs in peak flu season (culture confirmed) are really flu, how did he arrive at this number?

I'm with 'Doshi' here. I work with these people. And, I've heard this argument before from the anti-vaxers because pharmaceutical reps are on the ACIP board. They belong there because they are experts on vaccine production issues, something that is critical to the ACIP recommendations. The ACIP gives a full accounting of their decision making process. It's transparent and published including a thorough discussion of the rationale for the final recommendations. If there was undue influence it would be visible.

So you're with Doshi here? Well for starters, he isn't condoning ACIP policy, just stating how they came to their policy decision. Dr. Doshi is also highly critical of influenza/vaccine studies as well as being a reviewer on another Cochrane report for Tamiflu. He also appears to be the American version of Ben Goldacre with regards to pharma shenanigans and co-author with Jefferson. I just thought you would like to know some background on him before proudly proclaiming, "you're with him" on anything.

Quote:

Or, we might be able to say the same thing about his position. He wouldn't be the first science 'maverick' to refuse to give up his pet hypothesis as the evidence accumulated against it.

It's not accurate to state it's his "pet hypothesis" when he's just collating the available data. You also need to recognise what the Cochrane Collaboration is and they make no bones about withdrawing reviews. Jefferson isn't operating in a vacuum and has to adhere to the standards that the Cochrane Collaboration have set forth, editorial oversight and peer-review. You have yet to form a cogent argument that focuses on showing errors in his work rather than just ad hom attacks.

Este

[Estellea]

Originally Posted by Skeptic Ginger

Originally Posted by pgwenthold

Well, Jefferson is pretty much, by his own admission, an outlier in his views of the field. Of course, he pitches it as a Brave Maverick Who Alone Knows the Truth, while everyone else are just a bunch of dupes.

That's interesting. Do you have any sources with more about the person?

Yes, being a pompous arse is a great reason to dismiss a body of work. Can we stick to the reviews please and this alleged discrepant mountain of studies? I don't care for Dr. Jefferson much myself; I don't agree with many things he says and I certainly don't think his association with some very unsavory characters is at all good for his credibility (and I know more dirt about him than you will ever dig up SG). But all that does for me is be hyper-critical of his work and his work leaves little room for doubt at this juncture.

The Atlantic article is rubbish so I don't feel compelled to go down that road and I have a tremendous amount of respect for Dr. Crislip but he's essentially doing the same thing that the CDC has done which is try to cobble together some studies (that aren't even evaluated for their methodology) post hoc to justify his belief.

Este

[Skeptic Ginger]

Originally Posted by kellyb

Treading lightly here.
I deeply respect and admire the spirit of this thread, where everyone is encouraged to try to look into their own propensity for confirmation bias, other biases, and even further - to try to see potential/probable biases in sources they trust, like Cochrane authors and ACIP members.

My thoughts are sort of all over the place on this, so I'm going to try to hone in on just one or two things.

Disclosure of my current bias potential/probability: I am email friendly with some MDs in developing countries who are very angry with and suspicious of the WHO and CDC.

Do try not to get this thread kicked back to the CT forum. If you have concerns about the CDC or WHO then you really need more to back that up than, I know a doc.

Originally Posted by kellyb

My question is: is this a good use of finite healthcare resources? I mean, we don't have collective universal HC in the US, and won't in the foreseeable future as far as I can tell, but most of the developed world does. Maybe there's a good reason that most developed countries think it's a poor use of finite resources?

As far as I'm concerned it's been a good use of my resources to give flu shots to my son and his friends every year.

And if you look at the ACIP, APIC, TJC and the Science Based Medicine contributor, Dr Crislip, you'll find an extensive discussion of the rationale for why flu vaccine is a good use of limited resources.

So far on the other side of the argument we have a single group headed by a guy who dismisses flu as a dangerous pathogen. He claimed we don't know what percentage of ILIs are flu when, in the US at least, we do indeed have 2 decades of hard data, the same data Jefferson opined we needed, showing what % if ILIs are culture positive flu.

Originally Posted by kellyb

In the US, it's like we pretend that HC resources are infinite when it comes to vaccines, and (sorry to be vague) I know for a fact (in an anecdotal way) that pharma companies are banking on that, and they're banking on it spilling over into WHO recommendations.

Unless you want to discuss facts and evidence the CT forum is that way ->

Originally Posted by kellyb

I do NOT believe the folks at the WHO are corrupt, pharma shills, or anything like that. I don't think ACIP members are, either. But there IS a thing that happens where pharma funds the snot out of researchers who are genuinely enthusiastic about their most lucrative products. And then they have these huge annual conventions, like this:
http://www.preventinfluenza.org/
and this:
http://www.clocate.com/conference/Th...es-2012/14970/

...where those super-funded, thus super-published, cherry-picked for their genuine enthusiasm researchers become the opinion leaders. And I find the way it all works problematic.

Health care and public health providers aren't ignorant dupes. Collectively we are well aware of the industry influence you are concerned about. We aren't politicians whose next campaign needs an influx of industry dollars, we are professionals who, for the most part, have pride in providing the best care for our patients we can.

You cite two legit conferences and assert they are corrupt because they didn't invite a nut job to speak? Honestly kelly, your CT beliefs about big pharma don't belong in this thread.

Originally Posted by kellyb

Back to flu: "we" still don't understand its epidemiology, etc well at all. When the dreaded pandemic actually hit in 2009, the pandemic strain knocked out the deadlier, older H1N1. The pandemic virus actually saved lives! And nobody talks about this! Maybe almost nobody even notices.
And that's not so weird when you watch how policy/research/expert symposiums work.

These comments suggest you have a very poor understanding of influenza and influenza epidemiology and what we do and don't know. What deadlier, older H1N1 strain are you referring to? Of course the 09 strain became the dominant strain. That's what new flu strains do. And this year another strain in the H3N2 clade is replacing the 09 strain as the dominant strain at the moment.

Originally Posted by kellyb

Maurice Hilleman, who I think was a highly moral person and a genius, to boot, was not invited to the influenza summits. But he had a "bad" opinion on flu in the policy climate. (the fact that he CREATED the flu vax could be ignored)

http://cmbi.bjmu.edu.cn/news/report/2005/flu/78.pdf

You'll need to tell us more about this supposed snub from whatever summit of several you are referring to. Are you suggesting that there is some conspiracy involving an entire scientific body of flu researchers and interested parties? Really? And Jefferson the lone maverick, along with Dr 'bizzaro' Hilleman know it's all a big pharma scam?

Here are some additional links on Hilleman that thread readers might be interested in:
The clueless cite the ignorant to argue against vaccines It's in the comments:

Quote:

This movie contained in the documentary “In Lies We Trust: The CIA, Hollywood & Bioterrorism, produced and created by the free association of consumer protection and by the public health, Dr. Leonard Horowitz, features the interview to as expert vaccines in the world, Dr. Maurice Hilleman, who explains why Merck has spread AIDS, leukemia and other terrible wounds in the world.

http://www.youtube.com/watch?v=edikv0zbAlU

Merck vaccine scientist Dr. Maurice Hilleman admitted presence of SV40, AIDS and cancer viruses in vaccines
Yep, that guy's real credible.

Originally Posted by kellyb

I'm scared of pandemic viruses. But I'm really skeptical of the idea that universal vaccination with a vaccine that often doesn't work, and very often doesn't work for the most at-risk groups, is a good use of healthcare resources that actually are finite even in the US.

Again the majority of the experts in this field in the US disagree.

The discussion is about looking at the evidence, not about nonsensical claims of CTs. Yes, Jefferson is convinced industry is slanting the science. That is a legit thing to discuss in the thread. But you don't do that by citing CT beliefs. You do that by citing very specific facts.

[Skeptic Ginger]

I'll try to go through your posts, not sure I'll get to every point but I'll try.

Originally Posted by Estellea

Yes, being a pompous arse is a great reason to dismiss a body of work. Can we stick to the reviews please and this alleged discrepant mountain of studies? I don't care for Dr. Jefferson much myself; I don't agree with many things he says and I certainly don't think his association with some very unsavory characters is at all good for his credibility (and I know more dirt about him than you will ever dig up SG). But all that does for me is be hyper-critical of his work and his work leaves little room for doubt at this juncture.

The Atlantic article is rubbish so I don't feel compelled to go down that road and I have a tremendous amount of respect for Dr. Crislip but he's essentially doing the same thing that the CDC has done which is try to cobble together some studies (that aren't even evaluated for their methodology) post hoc to justify his belief.

Este

No one dismissed Jefferson out of hand and yes, I have read a very good many of the studies and the Cochrane Reviews. I've been in this specific field of medicine for 22 years now.

I pointed to very specific facts Jefferson has wrong about estimating the morbidity and mortality of influenza. I cited a source outside of the Cochrane Review where his personal beliefs about influenza disease and the vaccine show he is not unbiased.

I showed where the vast majority of the interested/knowledgeable medical community who has considered Jefferson's reviews do not find them convincing.

I agree Cochrane Reviews are supposed to be the gold standard. But does that mean we can never question them? Dr Crislip and I have the same views on this matter. You trust him but you seem to think I'm just refusing to look at the evidence. No, I'm not refusing to look or or take the evidence seriously. I just don't think that in this case, the CRs reflect the actual body of research out there. And I'm definitely not convinced all the research is coming out of the drug company labs.

I'm hoping to see more evidence posted in this thread. Something akin to the ACIP discussion put out by the related UK or EU organizations would be nice. They seem to publish more summaries and are less transparent about the decision making process but that could just be because I'm not looking at the right sources.

[Professor Yaffle]

I have no problem with anybody questioning a Cochrane review - but for me that means criticising the methodology; how the papers were selected for inclusion; the types of analysis done; whether the conclusions are justified from the results. It doesn't mean discarding the results because they don't fit in with what you think you already know, or because you disagree with the authors prior stated opinion.

[kellyb]

This is what I absolutely deserve for believing you were operating in good faith, Ginger. I should have known better.

I say:

Quote:

"I'm scared of pandemic viruses. But I'm really skeptical of the idea that universal vaccination with a vaccine that often doesn't work, and very often doesn't work for the most at-risk groups, is a good use of healthcare resources that actually are finite even in the US.

...And you call that a CT.

Whatever, yo. Keep on advocating an idea that a vast majority of the world has rejected. Have fun with that.

Quote:

These comments suggest you have a very poor understanding of influenza and influenza epidemiology and what we do and don't know. What deadlier, older H1N1 strain are you referring to?

LOL!
I'll go out on a limb here and guess that Estellae and Dymanic know exactly what I'm talking about. But I'll give you cliff notes: Any time a new pandemic flu strain emerges and becomes dominant, it knocks out a previous strain. It eradicates it. But nobody knows why or how that happens. (and the "old" H1N1 killed a lot more folks yearly) If you think influenza is better understood, that just demonstrates that you lack the understanding to even have a clue about what matters that you don't know.

This:

Quote:

What deadlier, older H1N1 strain are you referring to?

I mean, really?

[Estellea]

Originally Posted by Skeptic Ginger

Health care and public health providers aren't ignorant dupes. Collectively we are well aware of the industry influence you are concerned about. We aren't politicians whose next campaign needs an influx of industry dollars, we are professionals who, for the most part, have pride in providing the best care for our patients we can.

You cite two legit conferences and assert they are corrupt because they didn't invite a nut job to speak? Honestly kelly, your CT beliefs about big pharma don't belong in this thread.

I think you missed the point of Kelly's mention of these conferences as examples of industry-funding and using key opinion leaders (KOLs) to influence others. Perhaps this might help:
http://www2.kenes.com/ISPPD/Sponsor/...xhibitors.aspx
http://www.preventinfluenza.org/nivs.asp
And she is absolutely correct about KOLs; they are paid fabulous sums of money in direct payments and gifts to speak very kindly about X, Y or Z pharma products.

Quote:

You'll need to tell us more about this supposed snub from whatever summit of several you are referring to. Are you suggesting that there is some conspiracy involving an entire scientific body of flu researchers and interested parties? Really? And Peterson the lone maverick, along with Dr 'bizzaro' Hilleman know it's all a big pharma scam?

Here are some additional links on Hilleman that thread readers might be interested in:
The clueless cite the ignorant to argue against vaccines It's in the comments:
Merck vaccine scientist Dr. Maurice Hilleman admitted presence of SV40, AIDS and cancer viruses in vaccines
Yep, that guy's real credible.

You are using dubious sources as some kind of proof that Dr. Hilleman is "bizarro"? You really don't know who Dr. Hilleman even is do you?

And who is Peterson?

Este

[Skeptic Ginger]

Originally Posted by Estellea

So you're with Doshi here?

I agree with the quoted sentence. That's all I was referring to.

Originally Posted by Estellea

Well for starters, he isn't condoning ACIP policy, just stating how they came to their policy decision. Dr. Doshi is also highly critical of influenza/vaccine studies

OK let's start with that one. He's a graduate student and it was published in 2005. A lot of research since that time has confirmed, not refuted, CDC's position on flu and flu vaccine.

Quote:

The Centers for Disease Control and Prevention (CDC) acknowledges a difference between flu death and flu associated death yet uses the terms interchangeably.

Tell me why it matters. You get flu and die of flu, or you get flu and die of secondary pneumonia. Both are potentially preventable with flu vaccine. He spends a good deal griping about conflating all pneumonia deaths and flu/pneumonia deaths. The CDC when referring to the annual flu deaths does not include non-flu related pneumonia in the figures and as I said and cited, they justify their numbers in detailed publications. It would seem both Jefferson and Doshi are uninformed here about what the numbers mean that the CDC cites.

Extensive culturing of ILI cases has been done since 2009 and the numbers confirm past estimates were not off base.

Quote:

Compounding these problems is a marketing of fear—a CDC communications strategy in which medical experts “predict dire outcomes” during flu seasons.

This is a gross misunderstanding of the facts and doesn't surprise me a Brit would be misled. It's not the CDC that plays up the fear mongering, it's our news media that sells sensation, fear and scandal. This was brought up time and time again during the 2009 pandemic. The CDC was very rational and factual and continually tried to correct the news media's misinformation.

He goes on to suggest the deal the US struck with flu vaccine manufacturers was suspect. To some degree it may have been. But to a larger degree it was a response to a repeating shortage of flu vaccine as manufacturers dropped out of the unprofitable market. We also had and still have a long legacy of public misperception about the dangers of flu vaccine since the 1976 GBS threat. The Flu Act was a joint venture not solely a drug lobby directed one. People not closely involved in US public health and US flu vaccine issues may not understand the intricacies unique to this disease and vaccine.

Originally Posted by Estellea

...as well as being a reviewer on another Cochrane report for Tamiflu. He also appears to be the American version of Ben Goldacre with regards to pharma shenanigans and co-author with Jefferson. I just thought you would like to know some background on him before proudly proclaiming, "you're with him" on anything.

Don't misquote me, I agree with the sentence I quoted. As for the Tamiflu issues, I'm continuing to evaluate that one. I'm aware of the controversy re effectiveness and Big Pharma's push to sell stockpiles of Tamiflu. It's a separate issue from the vaccine research.

As for recent concerns about drug company research being suppressed when it is negative, this is a serious issue the health care community is not oblivious to. But when it comes to flu vaccine research, we aren't talking about the same thing. If a drug company funds a study done through a university, it cannot hide the results if it doesn't like the outcome. These are not, for the most part, studies the drug companies are conducting in secret.

Originally Posted by Estellea

It's not accurate to state it's his "pet hypothesis" when he's just collating the available data. You also need to recognise what the Cochrane Collaboration is and they make no bones about withdrawing reviews. Jefferson isn't operating in a vacuum and has to adhere to the standards that the Cochrane Collaboration have set forth, editorial oversight and peer-review. You have yet to form a cogent argument that focuses on showing errors in his work rather than just ad hom attacks.

Este

One would think compiling data using rigid guidelines would not be subject to personal hypotheses. However, there has to be a reason these reviews differ from the main body of research. You could suspect undue Big Pharma influence in the research is the reason.

But I have reason to believe that is not the case. For one, a lot of what CDC has put out about influenza was at the time Big Pharma was dropping out of the flu vaccine market right and left because profit was not there. The idea flu vaccine has always been this hugely profitable market isn't true.

And the second reason is I can see with specific facts that the CDC is not overestimating influenza burden yet a lot of the criticism is based on an underlying premise that the disease burden has been overestimated. And that has gone into the CR assessment especially when it comes to anything referring to ILIs.

Logic suggests if two underlying premises are true, the vaccine works at least some of the time, and previously healthy people suffer serious morbidity and mortality from influenza, then what is it the CR is seeing in the data? If they underestimate the true burden of influenza, they could be falsely diluting the vaccine benefits in the study findings they reviewed.

How do you explain it? One of the two underlying premises are not true? Or something else?

[Skeptic Ginger]

Originally Posted by Estellea

...

And who is Peterson?

Este

A sign of aging. Somewhere yesterday my brain mixed up Jefferson and Peterson. They're probably indelibly confused in my brain now.