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Old 23rd January 2013, 11:45 AM   #41
Professor Yaffle
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SG - with that stuff you posted to dismiss Hilleman, you just lost pretty much any respect I had for your opinion.
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Old 23rd January 2013, 11:45 AM   #42
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I don't think she knows who Hilleman is.
Yet she thinks herself some sort of expert on vaccines.
Because she (correctly) knows how to give Hep B prophylactics, etc.

I take no issue with the ACIP on prophylactic Hep B measures. But being able to do that isn't the same thing as really delving deep into the very messy world of WHO and ACIP recommendations when it comes to global recommendation with questionable products.
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Old 23rd January 2013, 11:49 AM   #43
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Originally Posted by Estellea View Post

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?
Was.

Quote:
Maurice Ralph Hilleman (August 30, 1919 – April 11, 2005)
http://en.wikipedia.org/wiki/Maurice_Hilleman
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Old 23rd January 2013, 12:03 PM   #44
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Quote:
Dr 'bizzaro' Hilleman
It would be funny if it wasn't so atrocious.
He only saved, oh, millions and millions of lives, and was the greatest virologist in history. The founder of modern virology.

Bizarro, indeed.

What the ****** f.
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Old 23rd January 2013, 12:12 PM   #45
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Originally Posted by Professor Yaffle View Post
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.
The CRs have been addressed. It's not easy to find links to things one has read over a 5-10yr time frame.

If you look at both Dr Crislip and the ACIP's discussion of the issue they essentially state the CRs contain a tiny fraction of the available data out there. To dismiss a mountain of research (Crislip refers to 14,400 plus influenza vaccine articles on Pubmed) and use only that tiny fraction can in some cases not give you better results.

Again, from Dr Crislip:
Quote:
I will say as an aside that the earlier Cochrane review suggested that influenza cases were decreased by 6% from the vaccine. One commenter over at my Medscate blog, drdan23 suggested that a 6% decrease in disease was not worth it. 30,000 direct and indirect deaths from influenza in the US, maybe 500,000 worldwide. 6% of 30,000 is 1800. 6% of 500,000 is 30,000. Only 6% decrease in deaths? I was always wondering who would be sitting on those death panels that Palin was talking about. It’s the anti flu vaccine docs....

Now it may be file drawer effect and negative studies are not being published. The studies show benefits from the vaccine, the benefit is variable depending on the circulating strain, the vaccine match and the population vaccinated. But a benefit none the less.
I know you're in the UK but did you notice the Canada data?
Quote:
The most compelling population data comes from Ontario, Canada, where they have had a ongoing attempt to maximize the vaccination of the whole population against influenza (PubMed). The other Provinces did not see fit to try and vaccinate everyone, continuing with targeted influenza vaccination.
This represents an interesting natural experiment. If the effects of the influenza vaccine are less in preventing disease but more in decreasing secondary endpoints like death, hospitalizations, or antibiotic usage, it may show up in population studies. There are numerous issues with this kind of study, but are “appropriate for assessing the public health impact of a population-wide intervention.”
During the period in the reference, Ontario experienced greater uptake of vaccine than any other Province:
“Between the pre-UIIP 1996–1997 estimate to the mean post-UIIP vaccination rate, influenza vaccination rates for the household population aged ≥12 y increased 20 percentage points (18%–38%) for Ontario, compared to 11 percentage points (13%–24%) for other provinces (p < 0.001) (Table 2). For those <65 y, the vaccination rate increases were greater in Ontario than in other provinces, while for those ≥75 y, the increase was smaller in Ontario. For all age groups, Ontario always achieved higher vaccination rates than other provinces.”
And the results of all that vaccination:
After UIIP introduction, influenza-associated mortality for the overall population decreased 74% in Ontario (RR = 0.26, 95% confidence interval [CI], 0.20–0.34) compared to 57% in other provinces (RR = 0.43, 95% CI, 0.37–0.50) (ratio of RRs = 0.61, p = 0.002) (Table 3). In age-specific analyses, larger mortality decreases in Ontario were found to be statistically significant only in those ≥85 y.”
Not Bad.

...The influenza vaccine is not 100% efficacious in preventing disease, but it is as close to 100% safe, and much safer than the disease.

This is something I've been trying to say about the CRs in general. Sometimes we don't have the perfect RCTs. Yes, the CRs are supposed to clarify the results we do have. But not every CR is as definitive as the concept implies. I think Dr Crislip does a good job of detailing why that is particularly true in the case of flu vaccine reviews.

From what I've read in the last couple days, I'll add that I suspect the reviews understate the flu vaccine benefit by using false assumptions about what the actual flu case numbers based on the ILI numbers used in the studies were.
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Old 23rd January 2013, 12:25 PM   #46
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Originally Posted by kellyb View Post
It would be funny if it wasn't so atrocious.
He only saved, oh, millions and millions of lives, and was the greatest virologist in history. The founder of modern virology.

Bizarro, indeed.

What the ****** f.
Deleted if it was an error.
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Old 23rd January 2013, 12:34 PM   #47
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Originally Posted by Professor Yaffle View Post
That's interesting since kellyb claims he was snubbed at recent flu conferences.

Also sounds like it needs another thread. Half the sites show what a great vaccine developer he was and a couple say he claimed vaccines cause cancer and HIV. None of that is in the Wiki entry so if it was false information I apologize.

Either way, it's off topic and this thread topic is complicated enough as it is without any side tracks.
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Old 23rd January 2013, 12:39 PM   #48
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Originally Posted by Professor Yaffle View Post
SG - with that stuff you posted to dismiss Hilleman, you just lost pretty much any respect I had for your opinion.
Gee thanks, I made a mistake. There were several links on a Google search that said he believed vaccines caused HIV and cancer. He wouldn't be the first respected scientist that went off with some woo belief at some time in his career.
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Old 23rd January 2013, 12:49 PM   #49
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Here, instead of griping at me here for something I found on the Net as if this means nothing I have to say matters, I started a thread to discuss it: Maurice Hilleman vaccine controversy. Apparently the anti-vaxers found a memo Hilleman supposedly wrote. And no, I have not paid previous attention to this memo CT.
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Old 23rd January 2013, 12:52 PM   #50
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Originally Posted by Skeptic Ginger View Post
Gee thanks, I made a mistake. There were several links on a Google search that said he believed vaccines caused HIV and cancer. He wouldn't be the first respected scientist that went off with some woo belief at some time in his career.
Well its the fact that you jumped straight to the conclusion that suited your argument (even though it was mostly repeated on wooish websites like Natural News), rather than trying to ascertain the facts.

For the curious, it was something said in a joking manner and taken out of context and spread around woo sites. As a second of closer examination could have told you (that's how long it took me).

http://www.wired.com/wiredscience/20...d-merck-bring/

ETA - sigh, the quote in the thread you started isn't even about the HIV thing... You really should slow down and think a bit more about your posts rather that going off half-cocked.

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Old 23rd January 2013, 01:44 PM   #51
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Originally Posted by Professor Yaffle View Post
Well its the fact that you jumped straight to the conclusion that suited your argument (even though it was mostly repeated on wooish websites like Natural News), rather than trying to ascertain the facts.

For the curious, it was something said in a joking manner and taken out of context and spread around woo sites. As a second of closer examination could have told you (that's how long it took me).

http://www.wired.com/wiredscience/20...d-merck-bring/

ETA - sigh, the quote in the thread you started isn't even about the HIV thing... You really should slow down and think a bit more about your posts rather that going off half-cocked.
I responded to a post that was all about a Big Pharma CT by a forumite who I know is a Big Pharma CTer. She claimed with no evidence that "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." That implies again with no evidence whatsoever, that people with certain legit but politically incorrect views were selectively excluded from 2 flu conferences.


Yes, I'm sensitive to having this thread devolve into a useless 20 page discussion of Big Pharma CTs. I want to discuss the issue of science contradicting science, and the blind faith in CRs, not Big Pharma CTs. Industry influence on research results occurs, and that is very much within the purview of the thread. But the nonsense that Big Pharma controls with a heavy hand, (like excluding legit views from a conference), the flow of vaccine and flu information is unsupportable nonsense and there are more than a few threads that topic can be discussed in.
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Old 23rd January 2013, 01:50 PM   #52
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Originally Posted by Professor Yaffle View Post
... As a second of closer examination could have told you (that's how long it took me).

http://www.wired.com/wiredscience/20...d-merck-bring/

....
If you know to look for it. That's what happens when other people do know and share what they know, and that's why I apologized for the error.
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Old 23rd January 2013, 02:09 PM   #53
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Originally Posted by Cuddles View Post
According to WHO guidelines, being a child is a risk factor.
That's true for the CDC guidelines as well. In addition, at least one analysis of pediatric flu deaths (2004 IIRC) found a fair percentage of the deaths occurred in kids with no identifiable risk factors (at the time an identified risk only included kids to age 5).

Three of the Cochrane Reviews in question (one review with 3 updates) concluded influenza vaccine in kids with no identifiable risk factors showed no measurable benefit, and studies on kids under age 2 were lacking altogether.

Vaccines for preventing influenza in healthy children
Quote:
The review authors found that in children aged from two years, nasal spray vaccines made from weakened influenza viruses were better at preventing illness caused by the influenza virus than injected vaccines made from the killed virus. Neither type was particularly good at preventing 'flu-like illness' caused by other types of viruses. In children under the age of two, the efficacy of inactivated vaccine was similar to placebo. It was not possible to analyse the safety of vaccines from the studies due to the lack of standardisation in the information given, but very little information was found on the safety of inactivated vaccines, the most commonly used vaccine in young children.
First off, flu vaccine is not intended to "prevent illness caused by other viruses". It makes you wonder what the heck they were reviewing? And if you combine that with Jefferson's public statements he believes influenza burden is overestimated because illness caused by other viruses are included in the risk estimate when estimating the vaccine benefit, it calls the review into question.

I have posted cites showing that the CDC has done a good job of estimating actual influenza including using the very method that Jefferson complains is needed but isn't done. And CDC has been measuring the % of culture confirmed influenza in random specimens from patients with ILIs for at least 2 decades. In addition more intense culture surveillance since 2009 in the US continues to support the numbers CDC has been using as the influenza morbidity and mortality burden.

And the CR above claims we don't have a good estimate of vaccine risks. I beg to differ. Analyses of the VAERs raw data has been carefully done. Particular attention is paid to influenza vaccine adverse events because of the GBS vaccine risk in 1976. Vaccine risks are discussed in detail in the ACIP Recommendations.

Now, there is less data on the newer MedImmune live attenuated vaccine but that is true for any new vaccine on the market.
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Old 23rd January 2013, 04:52 PM   #54
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Originally Posted by Skeptic Ginger View Post
I agree with the quoted sentence. That's all I was referring to.
I just wanted to make sure you knew who he was and that he wasn't condoning ACIP policy, just saying how it got there. This is in stark contrast to what you have been claiming which is that ACIP influenza vaccine policy is strictly evidence-based because it isn't.

Quote:
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.
I don't care if he was in pre-K when he published that; it still holds and you haven't presented any evidence that refutes him. I don't suppose you have noticed that the CDC however has changed it's annual flu fatality rates as a reflection of what Dr. Doshi has criticised.
Quote:
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.
It is all explained in the BMJ article. I'll grant that he is unclear but he is criticising (rightfully) that influenza and influenza-related fatalities are being lumped together although influenza was never confirmed in most cases.
Quote:
Extensive culturing of ILI cases has been done since 2009 and the numbers confirm past estimates were not off base.
Citations?

Quote:
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.
Neither Jefferson nor Doshi are "Brits". I guess you missed the part at the end of the BMJ article that links to the “Seven-Step `Recipe' for Generating Interest in, and Demand for, Flu (or any other) Vaccination”? OMH I'm channelling Kellyb.

Quote:
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.
I'm afraid that you are being very very naive here. Yes, influenza vaccines are not very profitable at all and their production needs to be subsidised. We need better vaccines which is also subsidised. We need a seamless manufacturing platform to meet a demand in the event of a pandemic. In order to accomplish that, an artificial demand is created to justify the expenditure; discarded, unused vaccines is not a good thing. Now making sure that sufficient vaccines can be produced when/if we get hit with a particularly nasty pandemic strain is not a bad thing as well as R & D for better vaccines. But there is a bit of duplicity on the part of public health officials to sell us this need.

Quote:
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.
I'm going to be generous and say you are being a Pollyanna here. Universities sign non-disclosure agreements; pharma companies can absolutely have academics test a product and then bury the results if they like; it is done routinely. Some unis have policies against this sort of thing but very few.

Quote:
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.
You have the full text; tear it apart. The methodology is all there. If you want an even more stark example, go ahead and do the same with the Cochrane Review on influenza vaccines in healthy children. And for some replication, you can read the CIDRAP meta-analysis and report that comes to virtually the same conclusions.

Quote:
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.
I explained that above.

Quote:
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.
Flu epidemiology is very ugly and yes, over-estimations are, without question, routinely made. We need standardisation of testing and reporting; I don't know how you can argue with that.

Quote:
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?
Again, you have a pathogen that causes ~10% of the respiratory disease burden in a given season, vaccine efficacy that have been grossly over-estimated, low uptake and influenza-related mortality guestimated. But again, look at their methods and results and see where, if any problems lay. I have and my critiques are minor in the grand scheme of things.

Este
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Old 23rd January 2013, 05:53 PM   #55
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Originally Posted by Estellea View Post
I just wanted to make sure you knew who he was and that he wasn't condoning ACIP policy, just saying how it got there. This is in stark contrast to what you have been claiming which is that ACIP influenza vaccine policy is strictly evidence-based because it isn't.
It's my opinion the ACIP is not only evidence based, they are transparent about which evidence they are basing recommendations on. Where do you see an ACIP recommendation not based on evidence?


Originally Posted by Estellea View Post
I don't care if he was in pre-K when he published that; it still holds and you haven't presented any evidence that refutes him. I don't suppose you have noticed that the CDC however has changed it's annual flu fatality rates as a reflection of what Dr. Doshi has criticised.
I very specifically cited evidence that contradicted the claims the CDC doesn't use valid numbers for influenza morbidity and mortality. For example, I cited very specific sampling of ILI cultures showing the weekly averages of culture positive %s that the CDC posts weekly every year from Oct to March (or April). Jefferson in his 2012 CR summary said such data did not exist. I don't know what his problem is. I've been checking those weekly what-%-are-culture-confirmed-flu numbers every flu season for 2 decades.

Does the CDC use valid flu morbidity and mortality numbers or don't they?

Wouldn't you expect an agency like the CDC to improve on their epidemiology numbers in a 20 year time frame?

Where is the evidence ILIs are used by the CDC as the actual numbers of influenza disease burden?

Originally Posted by Estellea View Post
It is all explained in the BMJ article. I'll grant that he is unclear but he is criticising (rightfully) that influenza and influenza-related fatalities are being lumped together although influenza was never confirmed in most cases.

Citations?
It's not a "rightful" criticism. His complaint is that non-influenza related pneumonia is being lumped together, but it isn't. (His issue is not that flu-related pneumonia being counted. That would obviously still be influenza caused illness.)

Overview of Influenza Surveillance in the United States

Does this sound like the CDC is counting all cases of pneumonia in the influenza data? :
Quote:
...Each week, the vital statistics offices of 122 cities across the United States report the total number of death certificates processed and the number of those for which pneumonia or influenza was listed as the underlying or contributing cause of death by age group...The percentage of deaths due to pneumonia and influenza (P&I) are compared with a seasonal baseline and epidemic threshold value calculated for each week. The seasonal baseline of P&I deaths is calculated using a periodic regression model that incorporates a robust regression procedure applied to data from the previous five years. An increase of 1.645 standard deviations above the seasonal baseline of P&I deaths is considered the “epidemic threshold,” i.e., the point at which the observed proportion of deaths attributed to pneumonia or influenza was significantly higher than would be expected at that time of the year in the absence of substantial influenza-related mortality.
Just because you see pneumonia deaths during flu outbreaks reported does not mean the CDC uses raw pneumonia cases when calculating influenza disease burden. Pneumonia and ILIs are a surrogate marker for increased flu activity, not for the total numbers cited as average influenza burden.

This is how the actual flu burden is verified, with cultures, again the complaint of Jefferson is cultures aren't used:
Quote:
Influenza Hospitalization Surveillance Network (FluSurv-NET) — FluSurv-NET conducts surveillance for population-based, laboratory-confirmed influenza related hospitalizations in children (persons less than 18 years) and adults. The network covers over 80 counties in the 10 Emerging Infections Program (EIP) states (CA, CO, CT, GA, MD, MN, NM, NY, OR, and TN) and five additional states (IA, MI, OH, RI and UT). Cases are identified by reviewing hospital laboratory and admission databases and infection control logs for children and adults with a documented positive influenza test (viral culture, direct/indirect fluorescent antibody assay (DFA/IFA), reverse transcription-polymerase chain reaction (RT-PCR), or a rapid influenza diagnostic test (RIDT)) conducted as a part of routine patient care. FluSurv-NET estimated hospitalization rates are reported each week during the influenza season.
Epidemiology of Seasonal Influenza: Use of Surveillance Data and Statistical Models to Estimate the Burden of Disease
Quote:
The US Centers for Disease Control and Prevention (CDC) uses a 7-component national surveillance system for influenza that includes virologic, influenza-like illness, hospitalization, and mortality data. In addition, some states and health organizations collect additional influenza surveillance data that complement the CDC’s surveillance system. Current surveillance data from these programs, together with national hospitalization and mortality data, have been used in statistical models to estimate the annual burden of disease associated with influenza in the United States for many years. National influenza surveillance data also have been used in suitable models to estimate the possible impact of future pandemics. As part of the public health response to the 2003–2004 influenza season, which was noteworthy for its severe effect among children, new US surveillance activities were undertaken.
They use the numbers, yes, but no one counts all cases of pneumonia and ILIs as cases of flu.

Here's an estimate of influenza mortality using a different model: Mortality due to Influenza in the United States—An Annualized Regression Approach Using Multiple-Cause Mortality Data
Quote:
The current research reevaluates attribution of deaths to influenza, by use of an annualized regression approach: comparing measures of excess deaths with measures of influenza virus prevalence by subtype over entire influenza seasons and attributing deaths to influenza by a regression model. This approach is more conservative in its assumptions than is earlier work, which used weekly regression models, or models based on fitting baselines, but it produces results consistent with these other methods, supporting the conclusion that influenza is an important cause of seasonal excess deaths. The regression model attributes an annual average of 41,400 (95% confidence interval: 27,100, 55,700) deaths to influenza over the period 1979–2001.
I don't see Jefferson (and Doshi in that editorial) criticizing the models, they criticize a false premise that the raw pneumonia deaths are all called flu deaths. I honestly don't understand their ignorance. It makes no sense to me whatsoever. If you can explain it or explain how they are saying something else, go for it.


Unless you think you covered it in the last half of your post. If that's the case wait til I'll get to the last half later. Out of time.

It would help if you stated what you think the annual influenza morbidity and mortality is and what you base that number on. You can use Jefferson's CR numbers if you believe them to be correct. What does he base them on?
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Old 24th January 2013, 09:31 AM   #56
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Originally Posted by Skeptic Ginger View Post
It's my opinion the ACIP is not only evidence based, they are transparent about which evidence they are basing recommendations on. Where do you see an ACIP recommendation not based on evidence?
The CIDRAP Meta-analysis and report that I have linked to at least a couple of times before this actually audited ACIP minutes and found this to be the case.

Quote:
I very specifically cited evidence that contradicted the claims the CDC doesn't use valid numbers for influenza morbidity and mortality. For example, I cited very specific sampling of ILI cultures showing the weekly averages of culture positive %s that the CDC posts weekly every year from Oct to March (or April). Jefferson in his 2012 CR summary said such data did not exist. I don't know what his problem is. I've been checking those weekly what-%-are-culture-confirmed-flu numbers every flu season for 2 decades.
Jefferson has conducted many Cochrane Reviews, could you specify which one you are referring to please? And be careful about stating "culture-confirmed" as that is not the case; many tests are accepted. Don't you wonder why vaccine status isn't included? Isn't that helpful information to provide better effectiveness estimates? I know they collect this data so why not be more transparent about it?

Quote:
Does the CDC use valid flu morbidity and mortality numbers or don't they?
They don't and I'll explain why.

Quote:
Wouldn't you expect an agency like the CDC to improve on their epidemiology numbers in a 20 year time frame?
You'd think but they explain mortality data collection difficulties here. And oh look, even though they use a problematic study to justify their claim, they have changed from claiming an average annual estimate from 36,000 to the range of 3,000 to 49,000.
Quote:
Where is the evidence ILIs are used by the CDC as the actual numbers of influenza disease burden?
Well, would their own case definition from the ILI Surveillance Network suffice?
Quote:
Case Definition of Influenza-like Illness: The outcome of interest monitored in this surveillance system is the number of clinical illness cases consistent with influenza (i.e. influenza-like illness or ILI) occurring in the general population. The ILI case definition used by CDC for national surveillance is fever ≥ 100°F° (≥ 37.8°C), oral or equivalent, AND cough and/or sore throat (in the absence of a known cause other than influenza). ILI cases must be identified based on the criteria outlined in the case definition.
Note that they aren't stating "confirmed influenza" but rather allowing for a differential diagnosis of influenza.

Quote:
It's not a "rightful" criticism. His complaint is that non-influenza related pneumonia is being lumped together, but it isn't. (His issue is not that flu-related pneumonia being counted. That would obviously still be influenza caused illness.)

Overview of Influenza Surveillance in the United States

Does this sound like the CDC is counting all cases of pneumonia in the influenza data? :Just because you see pneumonia deaths during flu outbreaks reported does not mean the CDC uses raw pneumonia cases when calculating influenza disease burden. Pneumonia and ILIs are a surrogate marker for increased flu activity, not for the total numbers cited as average influenza burden.
Yes it is the CDC counting all cases of pneumonia (without another known cause) as influenza-related. Didn't you read it? It's the very same model that Doshi criticised (Thompson et al.).
Quote:
122 Cities Mortality Reporting System —Each week, the vital statistics offices of 122 cities across the United States report the total number of death certificates processed and the number of those for which pneumonia or influenza was listed as the underlying or contributing cause of death by age group (Under 28 days, 28 days –1 year, 1-14 years, 15-24 years, 25-44 years, 45-64 years, 65-74 years, 75 84 years, and ≥ 85 years). The percentage of deaths due to pneumonia and influenza (P&I) are compared with a seasonal baseline and epidemic threshold value calculated for each week. The seasonal baseline of P&I deaths is calculated using a periodic regression model that incorporates a robust regression procedure applied to data from the previous five years. An increase of 1.645 standard deviations above the seasonal baseline of P&I deaths is considered the “epidemic threshold,” i.e., the point at which the observed proportion of deaths attributed to pneumonia or influenza was significantly higher than would be expected at that time of the year in the absence of substantial influenza-related mortality.
I really can't believe you can't see this. They take a sample of pneumonia OR influenza as the contributing or under-lying cause, used background influenza estimates and a statistical application that caused an inflation of influenza-related deaths. You can't just use pneumonia as a surrogate for influenza; it's insensitive and non-specific given all of the other respiratory diseases and underlying causes for that pneumonia other than influenza. That is Doshi's complaint. And even the lead author concurs:
Quote:
William Thompson of the CDC's National Immunization Program (NIP), and lead author of the CDC's 2003 JAMA article, explained that “influenza-associated mortality” is “a statistical association between deaths and viral data available.” He said that an association does not imply an underlying cause of death: “Based on modelling, we think it's associated. I don't know that we would say that it's the underlying cause of death.”
Quote:
This is how the actual flu burden is verified, with cultures, again the complaint of Jefferson is cultures aren't used:

Epidemiology of Seasonal Influenza: Use of Surveillance Data and Statistical Models to Estimate the Burden of DiseaseThey use the numbers, yes, but no one counts all cases of pneumonia and ILIs as cases of flu.
Again, not all verifications are culture-confirmed, it is more appropriate to say "lab-confirmed". I would suggest you actually read the methods because they do assume pneumonias without specific non-influenza causes are related to influenzas. And again, you'll have to show the specific instance that Dr. Jefferson makes the complaint cultures aren't used at all.
Quote:
Here's an estimate of influenza mortality using a different model: Mortality due to Influenza in the United States—An Annualized Regression Approach Using Multiple-Cause Mortality Data

I don't see Jefferson (and Doshi in that editorial) criticizing the models, they criticize a false premise that the raw pneumonia deaths are all called flu deaths. I honestly don't understand their ignorance. It makes no sense to me whatsoever. If you can explain it or explain how they are saying something else, go for it.
That is almost the same model that Thompson et al. used and even if you have a great statistical model, garbage in = garbage out (GIGO). Are you even reading methods? Here:
Quote:
Instead of using only the listed ‘‘underlying’’ cause of death, we tabulate all deaths with a specific cause—either pneumonia and influenza causes or all respiratory and circulatory causes—listed anywhere on the death certificate. We expect these ‘‘multiple-cause’’ data series to be more robust, both because more deaths are
included and because considering all causes on the death certificate should make these series less sensitive to coding and nosologic changes (figure 1).
While they increased sensitivity by expanding their death code search, they decreased specificity which is going to lead to an even larger over-estimate. They even admit they are using very imprecise data to estimate CODs attributable to influenza.
Quote:
It would help if you stated what you think the annual influenza morbidity and mortality is and what you base that number on. You can use Jefferson's CR numbers if you believe them to be correct. What does he base them on?
I don't recall that he chimes in with a specific number but rather states that estimates are over-estimated for a number of reasons. I think we could shorten this conversation considerably if you would actually read the review in the OP and make specific critiques. All you have done so far is post other links that are either simply at odds with his results but with no merit as I have explained or not particularly relevant. Would you try looking at his actual methods and frame your argument from there?

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Old 24th January 2013, 10:52 AM   #57
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Originally Posted by Skeptic Ginger View Post
I responded to a post that was all about a Big Pharma CT by a forumite who I know is a Big Pharma CTer. She claimed with no evidence that "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." That implies again with no evidence whatsoever, that people with certain legit but politically incorrect views were selectively excluded from 2 flu conferences.
I wasn't going to respond to this but just read your edit. Your overt attempt to poison the well regarding Kelly's statements is noted. Most of her statements had merit and were relevant to the topic in regards to the influence Pharma has on information disseminated. I wonder how you justify this attack and your woefully ignorant attack on Dr. Hilleman when you don't even know who he is nor his body of work that places him as probably one of the greatest vaccinologists in history in addition to your ignorance of pharma shenanigans. You pay lip service to the knowledge that they occur, just somehow they magically don't intrude on your little corner of the world.


Quote:
Yes, I'm sensitive to having this thread devolve into a useless 20 page discussion of Big Pharma CTs. I want to discuss the issue of science contradicting science, and the blind faith in CRs, not Big Pharma CTs. Industry influence on research results occurs, and that is very much within the purview of the thread. But the nonsense that Big Pharma controls with a heavy hand, (like excluding legit views from a conference), the flow of vaccine and flu information is unsupportable nonsense and there are more than a few threads that topic can be discussed in.
Sensitive or embarrassed? There were no "Big Pharma CTs" introduced and it is both offensive and amusing that you would label those of us defending Cochrane Reviews as having blind faith when you can't seem to do anything but cherry-pick studies, blather ignorantly about how academic institutions don't do anything naughty with regards to publication biases and ad hom attacks. Your passive-aggressive comment about "Brits" probably not being able to understand CDC data is a dandy too. You haven't even critiqued Jefferson's methodology nor evaluated any of the studies you introduced for methodological quality. You agreed with a statement by someone who is anti-thetical to your dogma just because he said something you liked. All in all making blatantly wrong statements about subjects you clearly don't have any experience in but fancying yourself an expert regardless. Confirmation bias in action. My opinion of you has really tanked after what I have witnessed here so unless you have something unique as in actually reading your own sources and the ones I have provided, not just saying you did and you simply don't agree, well then it's obvious you either don't know how to properly evaluate these studies and/or simply refuse to budge from your dogma, then I probably don't have much to add.

Este

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Old 24th January 2013, 11:47 AM   #58
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Poison the well? I've had multiple thread long debates with kelly on vaccine issues, am I supposed to pretend I don't know her Big Pharma position?

I'll get to the rest sometime today including going back to the 'Hilleman was snubbed' claim.
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Old 24th January 2013, 12:09 PM   #59
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Originally Posted by Skeptic Ginger View Post
Poison the well? I've had multiple thread long debates with kelly on vaccine issues, am I supposed to pretend I don't know her Big Pharma position?

I'll get to the rest sometime today including going back to the 'Hilleman was snubbed' claim.
I've had some stellar knock-down-drag-outs with Kelly (elsewhere). It's no excuse for painting her as a craxxy CT'er and dismissing her relevant comments in this thread. Not even knowing who he is and calling Dr. Hilleman "bizarro" doesn't exactly bolster your position either.

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Old 24th January 2013, 12:35 PM   #60
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So here we have a thread with the potential for a continuing good discussion about the science of flu vaccination devolving into still another pissing contest. Too bad! How about getting back to the science?
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Old 24th January 2013, 04:14 PM   #61
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Originally Posted by Perpetual Student View Post
So here we have a thread with the potential for a continuing good discussion about the science of flu vaccination devolving into still another pissing contest. Too bad! How about getting back to the science?
Thanks, that's what I intend to do.
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Old 24th January 2013, 04:29 PM   #62
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I'm going to continue taking a piece at a time, starting with an easier one. It doesn't mean I won't go back to the other points.
Originally Posted by Estellea View Post
...
They don't and I'll explain why.


You'd think but they explain mortality data collection difficulties here. And oh look, even though they use a problematic study to justify their claim, they have changed from claiming an average annual estimate from 36,000 to the range of 3,000 to 49,000.

Well, would their own case definition from the ILI Surveillance Network suffice?... [snip]
This represents a misunderstanding of ILI surveillance.

Yes, ILIs are defined and monitored. They represent a correlate. ILIs correlate with circulating influenza in a community including serving as an indicator for determining when the influenza epidemic threshold is reached or exceeded. And ILIs can be confirmed as being a consistently valid indicator of influenza activity.

But influenza morbidity and mortality is derived from multiple data collections and raw ILI numbers are not counted as raw influenza numbers. It's basic epidemiology. Which is why I don't understand Doshi's and Jefferson's condemnation of ILI and pneumonia surveillance. They must know CDC doesn't call all ILIs and pneumonia influenza.
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Old 24th January 2013, 05:16 PM   #63
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Originally Posted by Estellea View Post
I just wanted to make sure you knew who he was and that he wasn't condoning ACIP policy, just saying how it got there. This is in stark contrast to what you have been claiming which is that ACIP influenza vaccine policy is strictly evidence-based because it isn't.
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Re the ACIP not making evidence based recommendations, I read through the relevant sections in the CIDRAP review. Claiming the ACIP doesn't use evidence is a strange interpretation of the piece. The reviewers gave a detailed critique of the ACIP process and findings. They concluded:
Quote:
In summary, the above example illustrates that the use of evidence-based recommendations by the ACIP will not necessarily support the strength of the actual evidence unless the criteria used are clarified and agreed upon by study design experts. Furthermore, standards are needed for evaluating the evidence beyond the GRADE criteria for influenza vaccine studies. Such standards should take into account variables such as diagnostic tests used to confirm influenza infection, study design, and potential for bias.
This is understanding medical research ~ level 301, I won't call it 101. With an extremely fine toothed comb the CIDRAP reviewers are not saying the ACIP hasn't made evidence based decisions. If anything the review shows they do a very thorough job. However, the reviewers are saying what everyone knows and what has not been denied by either myself or Dr Crislip. They find the recommendation to use influenza vaccine for the whole population is based on imperfect research. That's not saying the ACIP is making completely unsupported recommendations.

This comes down to medical philosophy. I had this discussion with Linda (fls) once and I'm sorry she isn't here to weigh in. I said my prescribing philosophy was
  • if there is some evidence of a potential benefit
  • if harm is unlikely
  • if one is not using an unproven treatment in lieu of a known better one
  • and if the cost is not a burden
then I would be fine with the intervention if a patient wanted it. Linda's position was not to recommend the treatment until there was solid evidence.

And it comes down to another issue in the case of universal flu vaccine recommendations, that is a difference of opinion, something that is obviously going to happen in cases like this. So the ACIP thought the evidence was strong enough and the CIDRAP group suggested ideally the evidence needed to be stronger.

To say the ACIP isn't making an evidence based recommendation is a serious misunderstanding of the CIDRAP review.

And I've already said that weighing the pros and cons of a recommendation depend on who the intervention is for. I see no drawback to universal flu vaccination recommendations unless vaccine has to be prioritized in a shortage. But were I evaluating the cost as an employer for my employees, or an NHS deciding how to allocate limited resources, different things go into the risk/benefit assessment.


I will continue to look at the other sections in the CIDRAP link.
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Old 24th January 2013, 06:09 PM   #64
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Considering you either haven't read or understand Thompson et al., Dushoff et al. and are blatantly abusing the CIDRAP Report (I would urge anyone interested to read for themselves A Review of ACIP Promulgation of Influenza Vaccine Recommendations of the CIDRAP report to see for themselves) for example:
Quote:
The minutes of the
ACIP meetings suggest that the ACIP moved toward
a recommendation for universal vaccination on the
basis of professional opinions from supporters of the
approach, rather than on compelling data, and on the
gradual development of a consensus among members
that this was the appropriate proactive strategy for
decreasing influenza morbidity and mortality. Again,
this approach is consistent with earlier patterns for
developing influenza vaccination policy.
So it appears as though you are not going to do this discussion the courtesy of reviewing relevant literature and not misrepresent other studies. Not to mention appealing to your own (non) authority and condescending to others.

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Old 24th January 2013, 08:15 PM   #65
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And this cherry-picking?
Quote:
In summary, the above example illustrates that the use of evidence-based recommendations by the ACIP will not necessarily support the strength of the actual evidence unless the criteria used are clarified and agreed upon by study design experts. Furthermore, standards are needed for evaluating the evidence beyond the GRADE criteria for influenza vaccine studies. Such standards should take into account variables such as diagnostic tests used to confirm influenza infection, study design, and potential for bias.
That's from the ACIP's FUTURE framework for recommendations. NOT what they have been using all along. That is really shameful; stop trying so hard to "win" and just honestly represent the literature. The CIDRAP report replicates pretty much what the Cochrane Reviews do for every age group and HCWs.

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Old 24th January 2013, 08:22 PM   #66
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Originally Posted by Estellea View Post
Considering you either haven't read or understand Thompson et al., Dushoff et al. and are blatantly abusing the CIDRAP Report (I would urge anyone interested to read for themselves A Review of ACIP Promulgation of Influenza Vaccine Recommendations of the CIDRAP report to see for themselves) for example:
Quote:
The minutes of the ACIP meetings suggest that the ACIP moved toward a recommendation for universal vaccination on the basis of professional opinions from supporters of the approach, rather than on compelling data, and on the gradual development of a consensus among members that this was the appropriate proactive strategy for decreasing influenza morbidity and mortality. Again, this approach is consistent with earlier patterns for developing influenza vaccination policy.
[frivolous insult snipped]

Este
Of course people should read for themselves. Who would disagree with that? And I would appreciate if people would recognize we don't all have infinite time to review every single piece of evidence on this topic.

Another point of contention, not evidence based vs some people don't find the evidence compelling are not the same criticism. So lets get that strait before we argue two different things.


I read the above CIDRAP paper quote as two people/groups with different professional opinions, the evidence supports or the evidence does not support is not always a clear cut black and white fact.

That's the point of this thread.

Here's another quote from the review:
Quote:
A systematic review of the ACIP minutes and statements revealed that two factors were apparently instrumental in shaping public health policies on influenza vaccination over the years. First, there was a strong desire on the part of the ACIP membership to prevent influenza-associated morbidity and mortality. Second, there was a growing sense of disappointment over the inability to vaccinate more Americans who were most at risk of influenza-related complications and over the lack of impact that vaccination was having on the overall influenza disease burden in the United States.
Does that sound like the reviewers found the ACIP was subject to some unethical Big Pharma influence? Does it sound like the complaint is, industry slanted research and duped ACIP members?

No, it says dedicated public health professionals had strong opinions about the benefit of vaccinating the public at large that the CIDRAP reviewers did not agree with.


In addition the criticism is not that there was evidence against the benefit, the complaint is there wasn't yet enough quality evidence. It's a big difference.


There are two key issues in this thread (I'm not done trying to look at what everyone has posted).

Knowledgable ethical professionals have different opinions on whether or not there is sufficient evidence to support a universal influenza vaccination recommendation.
I think there is and I'm not worried that confirmation bias is making me wrong. My confirmation bias is based on my professional knowledge and the literature I've looked at.

It's perfectly legitimate for other professionals to say they don't think the evidence is there. They also are not necessarily letting their own confirmation bias lead them astray.

It's possible for professionals to come to different conclusions.

I would, however, argue that there is not evidence against universal vaccination recommendations.
And that leads me to the other main contention in the thread, that of claiming the CDC uses data that exaggerates the influenza burden.
In this case there is clear evidence and we aren't talking about the opinion to recommend or not recommend an intervention. And I'm not sure yet why Jefferson is so convinced the CDC numbers are exaggerated. Jefferson complains certain data is lacking and I cited 2 decades of weekly flu cultures of ILI nasal specimens. I'm still trying to figure out what's going on there.

I believe (yes opinion, nothing more) when the dust settles on this controversy we are going to find the CRs resulted in a barrier to moving forward but the evidence will end up exonerating the public health officials who correctly read the evidence trend. There's confirmation bias on both sides of this debate which I find fascinating. I also find it consistent with my experience that resulting from the vaccine history (in particular 1976 GBS matter), there are so many preconceived beliefs about influenza and flu vaccine that it has resulted in flu and flu vaccine being treated differently than other vaccines except maybe the anthrax vaccine (which was a smaller scale).

A study Dr Crislip also cited:The Effect of Universal Influenza Immunization on Mortality and Health Care Use
Quote:
Conclusions

Compared to targeted programs in other provinces, introduction of universal vaccination in Ontario in 2000 was associated with relative reductions in influenza-associated mortality and health care use. The results of this large-scale natural experiment suggest that universal vaccination may be an effective public health measure for reducing the annual burden of influenza.
That's pretty damn compelling evidence for a universal influenza vaccination recommendation.
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Old 24th January 2013, 08:38 PM   #67
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Originally Posted by Estellea View Post
And this cherry-picking?

That's from the ACIP's FUTURE framework for recommendations. NOT what they have been using all along. [more frivolous insults snipped] The CIDRAP report replicates pretty much what the Cochrane Reviews do for every age group and HCWs.

Este
I think you're misreading that, but nonetheless, the paper is 125 pages long plus another ~65 pages of appendices. I quoted paragraphs that illustrated the paper is saying they think the ACIP jumped the evidence gun.

Nothing in the sections I read said the ACIP was not using evidence to base their recommendations on. Everything in that paper said the reviewers don't agree the evidence is strong enough yet and they would disagree with the ACIP committee.

This is normal peer review. It's not the condemnation of the ACIP or the universal vaccination recommendation you seem to think it is. Quote any part of the review you want.

As for agreeing with the CR, it depends on what you believe the two conclusions are. If you believe the conclusion was the studies aren't yet conclusive enough, then they concur. But if you believe both support the conclusion the evidence is lacking because the universal vaccination is of no benefit, then I don't think the papers agree.

And maybe that nuance is part of the problem here. People are reading the CRs as if they are saying the evidence is against a benefit rather than just not yet proving one. I think Jefferson (CRs) is saying you won't find a benefit and that seems to be his stated opinion.
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Old 24th January 2013, 09:57 PM   #68
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In defense against cherry picking accusations and claims I'm not reading the CIDRAP report objectively: CIDRAP on their own report:
Quote:
None of this means that people should skip getting a flu shot, the authors say. "I've received my flu shot this year," said CIDRAP Director Michael T. Osterholm, PhD, MPH, lead author of the report, at a press conference today.

"We urge people to get their flu shot," he added in a university press release. "The present vaccines are the best interventions available for seasonal influenza. However, these vaccines do not offer consistent, high-level protection—especially in individuals at risk of medical complications or those aged older than 65 years. Unfortunately, these are the populations where we need the vaccines to work the best."

Experts contacted about the report were generally positive about its depth and findings, though there was some concern over how the media might portray the information.

Looking Back at the CIDRAP Influenza Vaccine Report
Quote:
Reaction to the report in the media and blogosphere was extreme. Roni Caryn Rabin wrote in the New York Times that the report was “a step tantamount to heresy in the public health world.” A blogger for Gaia Health wrote that the report shows that “the vaccines now in existence simply aren’t any good.” Public health officials, however, were quick to point out that the report acknowledged that the influenza vaccine provides moderate levels of protection against influenza and has a good safety profile. And one of the report’s authors, Michael T. Osterholm, MD, in the same New York Times article that alleged heresy, noted “I say, ‘Use this vaccine’ … The safety profile is actually quite good. But we have oversold it. Use it — but just know it’s not going to work nearly as well as everyone says.”
Now you can cherry pick "we've oversold it" and claim it means the vaccine has been marketed for profits, by duped providers or coconspirators, or you can read these comments as they are intended, the efficacy is more modest than we would like but the disease is still serious and the vaccine worth getting.
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Old 25th January 2013, 01:04 PM   #69
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A little more to address the cherry picking accusation.

This seems to be some of the most 'ACIP isn't going by the evidence' specifics in the CIDRAP review:
Quote:
Finally, the ACIP statement includes studies in which the results were not reported accurately. For example, the 2010 ACIP guidance document states, “When the vaccine and circulating viruses are antigenically similar, TIV prevents laboratory-confirmed influenza illness among approximately 70% to 90% of healthy adults aged <65 years in randomized controlled trials.” 9 Five references were provided in the ACIP document to support this statement. Two referenced studies did not include laboratory confirmation for illness, 52,53 one is a review (which included the other studies that were cited), 54 one reported 2 years of outcomes, but one year’s results did not support the ACIP statement, 55 and one was included in our recent Lancet Infectious Diseases review of influenza vaccine efficacy and effectiveness, reporting efficacy of 68% for RT-PCR and culture-confirmed illness; these results come very close to meeting the ACIP mark of at least 70% efficacy. 56 In this study, though, all the participants were under the age of 49, with a mean age of 23.2. 56 Only one study reported laboratory confirmed data that actually support the ACIP criteria 55; however, this study did not fit the criteria for inclusion in our Lancet Infectious Diseases review, as laboratory confirmation was a fourfold rise in HAI antibody titer between acute and convalescent serum samples. Two studies included in our recent Lancet Infectious Diseases review of influenza vaccine efficacy and effectiveness fit the criteria for this ACIP statement and were publicly available at the time the draft recommendations were being written but were not included in the final ACIP statement. 57,58 Both of these studies reported influenza vaccine efficacies below 70%.
It's very easy to misunderstand that as questioning the ACIP's recommendations outright. That is not a condemnation of the ACIP recommendations, only of the strength of the evidence for the efficacy cited. As I noted in the last post, the lead reviewer said that was not their conclusion and he himself had gotten a flu vaccine this season.

Here's another CIDRAP comment further summarizing what the reviewers were actually saying:
Quote:
Last year a meta-analysis raised questions about the effectiveness of standard flu vaccines. The strict meta-analysis of high-quality randomized controlled trials, published in Lancet Infectious Diseases last October, put seasonal flu vaccine efficacy at 59% for adults younger than 65, which was lower than commonly cited 70% to 90% estimates.
And of course flu severity varies from season to season and within the season since we typically have more than one strain circulating, and the vaccine effectiveness varies as well. One must consider any 'average' with that in mind. And more importantly, the younger and healthier you are, the better the vaccine seems to work. The OP discussion is specifically about using the vaccine in people without identified risk factors.

There's a difference between, "the ACIP has overstated the effectiveness as we interpret the evidence" and "the ACIP recommendations are not evidence based."

I don't have an issue with the review conclusions. I've been looking for but not yet found a reply by the ACIP to the review. The CIDRAP reviewers note the ACIP is changing (as is everyone who is trying to improve evidence based medicine) to weighted evidence based recommendations. Most relavent agencies report recommendations on a scale of 1-4 as to how strong the evidence is supporting the recommendation.

I expect the ACIP will change to that format with the next full report on flu vaccine, probably in the 2013-14 flu season. (2010 was the last complete ACIP flu vaccine recommendation with 2011 and 12 just getting updates.)
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Old 25th January 2013, 07:36 PM   #70
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Back to the distraction, apparently Dr Jefferson showed up on Gary Null's radio program recently. Null is extreme anti-vax. Sorry, you don't want to be associated with anti-vax lunacy, then don't hang out with anti-vax loons
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Old 25th January 2013, 08:06 PM   #71
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Originally Posted by pgwenthold View Post
Back to the distraction, apparently Dr Jefferson showed up on Gary Null's radio program recently. Null is extreme anti-vax. Sorry, you don't want to be associated with anti-vax lunacy, then don't hang out with anti-vax loons
It's not a distraction. It's one issue I'm looking at in the thread to address the Cochrane Reviews Jefferson's headed on flu vaccine outcomes in healthy children and adults.

But when you say "showed up on" do you mean Null quoted Jefferson or interviewed him? It's not a surprise anti-vaxers quote Jefferson. He rants about undue Big Pharma influence and makes statements influenza is an overrated pathogen. His opinions also happen to fall outside or at least to the edge of the mainstream.


I was comparing the CRs with the meta-analyses published in the Lancet a year ago (see my last post). I was struck by the language in the plain language summary in the CR compared to the language in the Lancet review article.

Compare the Lancet review summary, Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis,:
Quote:
Interpretation
Influenza vaccines can provide moderate protection against virologically confirmed influenza, but such protection is greatly reduced or absent in some seasons. Evidence for protection in adults aged 65 years or older is lacking. LAIVs consistently show highest efficacy in young children (aged 6 months to 7 years). New vaccines with improved clinical efficacy and effectiveness are needed to further reduce influenza-related morbidity and mortality.
to the CR headed by Jefferson, Vaccines to prevent flu in Healthy Adults:
Quote:
Authors of this review assessed all trials that compared vaccinated people with unvaccinated people. The combined results of these trials showed that under ideal conditions (vaccine completely matching circulating viral configuration) 33 healthy adults need to be vaccinated to avoid one set of influenza symptoms. In average conditions (partially matching vaccine) 100 people need to be vaccinated to avoid one set of influenza symptoms. Vaccine use did not affect the number of people hospitalised or working days lost but caused one case of Guillian-Barré syndrome (a major neurological condition leading to paralysis) for every one million vaccinations. Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration. Our results may be an optimistic estimate because company-sponsored influenza vaccines trials tend to produce results favorable to their products and some of the evidence comes from trials carried out in ideal viral circulation and matching conditions and because the harms evidence base is limited..
(bolding mine)

The first thing I'd like to dispense with is the false claim that the flu vaccine caused any GBS cases. There were no vaccine GBS cases in many flu vaccine years. I already addressed that. Jefferson, et al, doesn't say theoretically, they state "did cause". For someone so strictly concerned with what the evidence actually supports, that sentence shows a biased conclusion, not an evidence based conclusion.

In addition, how ironic to not accept the CDC's conclusions on vaccine effectiveness and flu burden, but then take the GBS number from the same agency? They use the meta-analysis results for vaccine benefit conclusion but not for vaccine risk?

And, if there was no benefit seen, how is it the vaccine company funding of studies affected the results? I also noticed that the claim vaccine company funded studies are more likely to show positive results is a generalization and while it has validity, it shouldn't apply to the studies analyzed if they were properly screened for methodology. It's a vague claim that maybe some negative results are missing, but the review presents no evidence such as comparing the non-vaccine company funded results to the vaccine company funded results to see if there was a difference.


Compare that CR summary with the statement of findings in the CR (bolding mine):
Quote:
Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates. Inactivated vaccines caused local harms and an estimated 1.6 additional cases of Guillain-Barré Syndrome per million vaccinations. The harms evidence base is limited.
Local harms? What, a sore arm?

Harms evidence was limited, and GBS cases were estimated, meaning they went with the CDC estimate, not some observed evidence.

Then in the plain language summary that modest effect on time loss becomes no effect on time loss and the estimate changes to caused one case of GBS per million doses. In the US that would mean 100 cases of vaccine caused GBS, something there is clear evidence in most years did not occur.

I see confirmation bias in the CR summary for the points I noted. You don't need confirmation bias in the review to still have confirmation bias in the conclusion. How is that different from the complaint with the ACIP efficacy estimate?


(I still need to get to the issue of measuring the disease burden.)
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Old 25th January 2013, 08:22 PM   #72
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I found the answer re Jefferson's being on the radio:

The Cochrane Collaborative’s Tom Jefferson makes the huge mistake of appearing on Gary Null’s show

Quote:
Now, it would appear, Jefferson has revealed either his utter cluelessness or his true colors. Take your pick. Why do I say this? Because a couple of weeks ago, he appeared on the Gary Null Show. Mark Crislip is all over it, in particular regarding the issue of this year’s flu season, which appears to have hit earlier and harder than average. His deconstruction is quite detailed and long even Orac-ian standards.
I'm on it, more to follow.

Quote:
None of that will, of course, stop me from taking my own swipe at Jefferson because I find it very disturbing that the head of the Cochrane Collaborative in charge of doing Cochrane systematic reviews and meta-analyses of flu vaccine efficacy and safety would agree to be interviewed by a quack much of whose quackery involves pure antivaccine nonsense. I suppose it’s possible that Jefferson didn’t know who Null was when he agreed to be interviewed, but come on! A quick Google search brings up the infamous documentary that Null made called Vaccine Nation and what Null says on his website about it...

...You can watch the whole thing here if you can stand it. It’s propaganda every bit as blatant and idiotic as that presented in the anti-vaccine magnum opus The Greater Good, so much so that I think someday I’ll have to subject myself to the movie and review it, because people do mention it from time to time, and antivaccinationists use it as “evidence” that vaccines are the root of all evil.
Wow, I am not the only one with concerns about the neutrality of the CRs Jefferson headed.
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Old 25th January 2013, 09:27 PM   #73
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I'm going to post a couple short things.

Re counting raw ILIs as raw flu which I said was ludicrous, everyone in the field knows better:
Dr Crislip summarizing a bit of history:
Quote:
This season it is influenza A H3N2 and influenza B that are causing most of the disease. A lot of disease. Emergency rooms are seeing an increase influenza like illness and it is often caused by influenza. In my hospitals specimens positive for influenza jumped from 2% of submitted specimens to 26% positive and we are almost out of influenza PCR assay kits.
This it the norm. This is what we do with raw ILI numbers. They are a correlate. When you see an increase in ILIs and it is flu season you are going to also have the % of cultures returning influenza to know what part influenza is playing in the picture.
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Old 25th January 2013, 09:48 PM   #74
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If you ever had the flu, and I mean the real flu where your temp shoots up to 103 and you can't sit up without feeling like you are going to faint, you would get the flu shot and hope for the best despite the research.
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Old 25th January 2013, 09:50 PM   #75
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Does anyone think Crislip's anecdotes aren't valid? Think the patients he refers to needing a ventilator didn't get flu cultures? Think he doesn't know what he's talking about?
Quote:
Despite the increase in cases, it is remarkable for what we are not seeing [currently]. While people are being admitted to the hospital with flu, and deaths are now increasing, unlike the H1N1 epidemic, the ICU is not filled with influenza patients on a ventilator.

The most remarkable aspect of the 2009 outbreak was how lucky we were. It still amazes me. We were maxed out in every ICU in my system. All ICU beds and ventilators were in use. If a patient came through the door needing a ventilator, we did not have one to offer. Someone was going to die we might have otherwise saved. And right as we reached our surge capacity, the epidemic peaked. No patients came in needing a ventilator for flu. Dodged that bullet.

This year we have had only a smattering of patients on a ventilator from influenza, no young people dying (20-30 year olds, there have been at least 20 pediatric deaths so far), no flu encephalitis (we had two deaths from CNS involvement in young people), no one on ECMO from influenza induced lung failure, no pregnant females with advanced influenza. Lots of morbidity, but different than 2009, milder than 2009. But it is still early in the season.
He's leading up to his comments on Jefferson's dismissal of the 2009 flu being no big deal.
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Old 25th January 2013, 09:54 PM   #76
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Originally Posted by Jodie View Post
If you ever had the flu, and I mean the real flu where your temp shoots up to 103 and you can't sit up without feeling like you are going to faint, you would get the flu shot and hope for the best despite the research.
Or if you ever saw a kid with no preexisting risk factors die from flu, you would get your own kids their flu shot.

It's not fear mongering. It's a risk benefit decision. As a teen my boyfriend was killed in a car accident. The only time I've ever not used a seatbelt since (not counting buses) was in a taxi in Mexico City that didn't have them. But I didn't get out of the taxi. I wanted to see the museum I was headed to. I took the risk, it was a knowledgeable decision.
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Old 25th January 2013, 10:02 PM   #77
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Whatever, I haven't had the flu in 15 years since the last bout, I get my flu vaccine religiously every fall just because it was that awful the last time I had it. There is no guarantee that the vaccine will protect you from other flu strains but it seems to be working for me so far.
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Old 25th January 2013, 11:00 PM   #78
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Originally Posted by Jodie View Post
Whatever, I haven't had the flu in 15 years since the last bout, I get my flu vaccine religiously every fall just because it was that awful the last time I had it. There is no guarantee that the vaccine will protect you from other flu strains but it seems to be working for me so far.
Minimal risk and inconvenience, like clicking a seatbelt, makes a potential benefit enough.
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Old 26th January 2013, 05:22 PM   #79
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Thread progress summary:

I'm glad there are a lot of views of the thread. I hope people are interested. I don't want to be talking to myself.

I still intend to look at Jefferson's and Doshi's dismissal of the flu burden.

I think we can say the evidence shows the vaccine to be less effective than some numbers used, it'll be interesting to see what numbers the ACIP uses for the vaccine next season. The CIDRAP review came out too late for this season's update.

But the evidence still shows the vaccine has an effect of 60%, just not 70-90%. 60% is not negligible. And we are talking about the benefit of flu vaccine in healthy people between the ages of 5-65 yrs. At least from the age of 5 to ~40yrs the vaccine efficacy was higher.

I haven't seen anything supporting the CDC uses ILIs as a direct number for flu cases. I have no explanation for how Jefferson would make this mistake. No one I know in the field believes ILIs are a direct count of the flu burden. It's an indicator of flu activity in the area, and you always have to see what % of the ILI reports are culturing positive for flu. More than that, you look to see what % of the cases are a strain match for the vaccine.

And 3 studies were published in the other thread (I'll cite them after I walk my dogs if I haven't already) that looked at pediatric flu deaths and found a fair number had no preexisting risk factors.

We know healthy people die from flu. The numbers may be small, but they are not zero. In addition Jefferson seems to have dismissed the mortality in younger people in the 2009 pandemic as trumped up. That's a common false belief people hold who look at total numbers instead of the shifted demographics of the fatalities. Also some people think public health agencies were responsible for fear mongering because those people falsely attribute the news media's sensationalizing to the public health. PHD messages their news releases were consistently considerably calmer than the mass media.

The thread question remains, shouldn't we be just as critical reviewing science even if it is supposed to be unquestionably superior, like a meta-analysis of RCTs? This has been a useful exercise for me because I would have, before this thread, not been likely to question a Cochrane Review.
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Old 26th January 2013, 06:35 PM   #80
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You should question the validity of all research. If you know your statistics you can tell whether the conclusions are accurate or not.
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