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One Flu Into the Cuckoo’s Nest*

“I don’t seem able to get it straight in my mind….”
― Ken Kesey, One Flew Over the Cuckoo’s Nest

Influenza is going gangbusters at the moment. I like going to Google Flu trends as well as the CDC flu site to see what flu is doing. Using Google searches as a surrogate for infections is an interesting technique that public health officials have tried with less success in other illnesses but is not without utility. Behaviors of populations can presage a problem, my favorite example is the first hint of the 1993 massive Cryptosporidia diarrhea outbreak in Milwaukee was a sudden shortage of Kaopectate and Peptobismol. It appears there are more patients with flu like symptoms this year than  at the height of the H1N1 epidemic of 2009. We have lots of flu like illness, and per the CDC there are buckets of confirmed influenzaflu, but so far the season, while probably having more cases than 2009, the outbreak is clinically not the same.

Compare and contrast, the two words that defined undergraduate liberal arts essay assignments. Get out your blue books and compare and contrast influenza outbreaks from 2009 and 2013. You have one hour.

The H1N1 epidemic was due to, well, influenza A H1N1. Only about 1% of the isolates are currently H1N1, so presumptively almost everyone is immune from prior infection or vaccination. That is what probably ends most epidemics: the herd has immunity and the virus can not longer spread in a population and the virus has to go into hiding in swine populations, biding its time until the population, and genetic shift, render the population susceptible again.

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.

Despite the increase in cases, it is remarkable for what we are not seeing. 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.

It is curious how the strains differ in their effects on populations. Maybe the H1N1 has modified the disease for H3N2, since infection and vaccination to H1N1 in some people can result in a more ‘universal’ antibody against flu. Immunity to influenza flu is not as simple as one antibody against one strain, since for the hemagglutinin and neuraminidase proteins there are multiple areas that can generate an antibody response. Some of these sites are variable and differ every year but some are conserved. If you are lucky enough to develop antibody against conserved regions you could potentially be immune to all influenza A. Or probably there are other factors with the H3N2 virus that result in different clinical manifestations. We will likely know is a year or two after the researchers have their opportunity to investigate the current flu season.

I would expect increased mortality this year from flu and I hope to be wrong:

The magnitude of the seasonal component was highly correlated with traditional measures of excess mortality and was significantly larger in seasons dominated by influenza A(H2N2) and A(H3N2) viruses than in seasons dominated by A(H1N1) or B viruses.

But not only from infection but from an increase in cardiac events:

These data suggest that influenza infections, particularly by A/H3N2 viruses, are directly associated with acute IHD-related events in older individuals.

At the moment it looks like we are having widespread flu and flu like illness but with less severe morbidity and less mortality. Of course, I speak from the perspective of a hospital based doctor in Portland Oregon, and as such have a narrow and probably not representative experience.  Everything is always better in Portland.  It will be interesting for someone with access to all the data to compare and contrast the two flu seasons in the years to come.

The one consistent question I get about the flu vaccine is “Does it work?”

Do not ask me that question if you don’t have at least 10 minutes to kill, because the answer is not yes or no. For some vaccines it is a binary answer and people like binary answers. Yes or no. Good or bad. I get the suspicion that those in the SCAM reality greatly prefer simple binary answers and do not deal will with uncertainty, spectrum and gradients of answers. Perhaps that is their defining characteristic. SCAM proponents seem to like black and white in a world of grey. Does the tetanus vaccine work? Yep. Everyone who gets the vaccine is protected from tetanus. Doe the influenza vaccine work? It depends on who is vaccinated, which vaccine, what the circulating strains are and how well the vaccine matches and what your end point for defining ‘works’ is.

Influenza is complex.

There is an interesting issue in medicine that is usually not explicitly discussed but comes up obliquely in the concept of number needed to treat. Sometimes, like pneumonia, we are treating an individual. Or the tetanus vaccine, where we are preventing an illness in an individual. Much of the time with prevention we are not only treating the individual but also populations. It is an interesting issue: applying population data to individuals. A given individual may gain no benefit from statins or the flu vaccine, whereas populations of often do.

That is one of the strengths and a public relations weakness of modern medicine. Ignoring the individual and treating populations in some circumstances can lead to marked improvement in every ones health, the ‘old rising tide lifts all boats’ approach to public health medicine. And people loathe not being considered a unique and special entity. Influenza vaccination is both a intervention for individual AND populations, since as the Googleflu trends graphs nicely demonstrate, influenza like illnesses affect populations and do so with remarkable rapidly. Look at the slope of those curves. They are almost vertical. I mean, whoa. That’s communicable.

Unlike other respiratory viruses, influenza can kill, directly and indirectly.  So while there are 200 causes of flu like illnesses, influenza is unique in its ability to routinely cause severe morbidity and mortality.  My ICUs do not fill up with rhinovirus and metapneumovirus infections and their complications.

So with influenza vaccination efficacy you can have a narrow perspective: does it prevent influenza in an individual (sometimes) or does it have more widespread population effects.  The problem with the other benefits to vaccination it is like the dog that doesn’t bark.

Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”

In part I do infection control for a living and we are successful when nothing happens, but people do not notice when nothing occurs, and I have to point out the benefits of events not happening. Potential benefits of flu vaccination include:

  • I don’t influenza.
  • I don’t get influenza and therefore don’t give it my Grandmother.
  • I don’t get the flu and do not pass it on to my hospitalized patient, who tend to die from nosocomial influenza.
  • I get influenza, but it is milder and I miss less work.
  • I get influenza and because it is milder and less infectious I don’t give it to my Grandmother.
  • Because my Grandmother doesn’t get influenza she does not have an exacerbation of her heart failure, diabetes, COPD etc.
  • My grandmother doesn’t get the flu and as a result doesn’t have a secondary  myocardial infarction or bacterial pneumonia and is not hospitalized and doesn’t die as a result.
  • My pregnant wife doesn’t get the flu (from me or due to vaccination) and as such does not have miscarriage or is not admitted to the hospital with ARDS from influenza.
  • My obese Uncle doesn’t get the flu (from me or due to vaccination) and is not admitted with ARDS from influenza.

I have discussed flu vaccination multiple times in the blog. The question is not IF influenza vaccination works. It does. It is the  magnitude of the effect and in what populations it is effective that is the question.   The preponderance of information suggests the for most of the endpoints above, the influenza vaccine has beneficial effects. It’s not a great vaccine but better than nothing.

Then there is the political issue as to whether the bang is worth the buck, whether the benefits of pushing flu vaccines are worth the time and resources. That is a calculus that I am not capable of independently deriving, my sense is the answer is yes, and those with more expertise in these areas than I say influenza vaccination is cost effective.

One aspect of the flu season does not change from year to year is the anti-vaccine crowd, who continue to repeat the same half truths and misrepresentations.  As I keep mentioning, they live in an alternative universe having quantum jumped  into a part of the multiverse where my standards of reality need not apply.

Perhaps the highest profile critic of the influenza vaccine is Dr. Thomas Jefferson of the Cochrane Group. He generally takes the narrow perspective on the efficacy of the flu vaccine, that of preventing a case of influenza in an exposed individual and argues that the clinical trials that demonstrate efficacy are too flawed to make recommendations. I have begged to differ.

Dr. Jefferson was interviewed for Gary Null’s radio show, and I have taken the time to make a transcript of the interview. It makes for an interesting read, and I used the opportunity to add some annotations.

A couple of caveats. First, spoken language is most certainly not written language and I have omitted some the false starts and stumbles. The typo master (me) can hardly complain about others errors. The few times I have been interviewed I have greatly appreciated the editing that made me appear more fluent than I actually am. Speaking coherently about complex topics extemporaneously is difficult and an ability that neither Dr. Jefferson nor Mr. Null have apparently mastered.

I would wonder why Dr. Jefferson would choose appear to be on this podcast, since Mr. Null has been so against flu vaccination in the past he has sued to prevent the distribution of H1N1 vaccine.  Mr. Null is a proponet of alternative medicines for cancer and HIV denialism.  I suppose an Englishman living in Rome cannot be expected to know who Mr. Null is and what is approach to medical care might be, although a little Google searching quickly finds that Mr Null is the antithesis of everything science based medicine supports. And my Dad taught me early that you can judge a man by the company he keeps. Still, guilt by association is not the most reliable way to analyze an intellectual position. It is better to evaluate what they say in their own words (Or really close. I am no transcriptionist, but I think I got it right. Double question marks (??) were words I could not understand).  [My annotations are in square brackets]:

Null: Lets Begin by saying hello to Dr. Thomas Jefferson. Nice to have to with us here today Dr. Jefferson.

Jefferson: Hello Gary.

Null: Hi. Dr. Jefferson is a former primary care physician from the UK who is now a leading investigator for the Infectious Disease research at the Cochrane Database Collaboration in Rome and he is the editor of their acute respiratory infection group and been the coordinator of the vaccine field which reviews existing peer reviews vaccine research which determines the accuracy and validity of scientific methodology used and the claims being made. And he was also an editorial board member of the Journal Vaccine and uh…Dr. Jefferson, our biggest concern today is that we have been led to believe that everyone beyond the age of 6 months should have a flu vaccination. We have been told that these vaccines are safe and effective for everyone. The we have an honest look at the literature. Here’s my question.

Can we say with certainly, based on good science, independent science, and a gold standard that it would include safety and efficacy for pregnant women, for women who might be taking chemotherapy,

[Patient with cancer and/or on chemotherapy can get a reasonable serologic response to the vaccine, although there are no studies of clinical efficacy.  We do extrapolate from healthy populations to less healthy populations with vaccines.  A reasonable approach, but not always reliable.  Most of the time if you develop an immune response to a pathogen there will be some degree of resistance to that infection, but not always.  As in all the clinical subsets mentioned by Mr. Null, the best approach is for their family caretakers to be immune and not pass on the virus to those at risk.]

or maybe on heart medication or statins,

[Probably a key population to get vaccinated, since influenza, especially the H3 strains, increase the risk for heart attack and vaccination can likely that 1:10 first trimester pregnancies were lost during the 1919 pandemic. Babies born during flu epidemics are more like to be smaller  and have lower lifetime earning potential. Smaller babies from influenza are perhaps stupider babies. Vaccination not only prevents influenza (and by extension death) in the mother but also prevents miscarriage. Vaccinated mothers are less likely to give influenza to their newborns. As to safety,  no problems for mother or fetus have yet been discovered. The miniscule amount of antigen in the vaccine appear to have no adverse effects on either the mother or the baby and would be dwarfed by the massive amount of viral antigen exposure as well as exposure to the adverse effects of the inflammatory response from wild influenza. None of these studies probably meet the standards demanded by Dr. Jefferson, but it is difficult to ignore such a preponderance of data.]

Pregnancy is part of… is a physiological state. It is the reason why our race is still on the planet. So there is nothing wrong with pregnancy. That is, it is normal.

[And potentially filled with influenza related complications.]

Pregnancy women therefore are healthy adults and we do know what the performance of the inactivated influenza vaccine is in healthy adults because there are quite a number of trials, clinical trials, that’s experiments, we summarize them, and to give you some idea, we need to vaccinate about 33 to 99 people to avoid one set of influenza symptoms.

[Again, the narrow perspective: maternal death, spontaneous abortion, smaller birth babies, post partum influenza in the newborn are additional worries and the data strongly points to benefit from vaccination. If you fail to consider the preponderance of information and the multitudinous effects of both influenza and vaccination, you do the whole topic a major, and distorted, disservice.  But that is Dr. Jeffersons modus operandi: Given that “worldwide, these annual epidemics result in about three to five million cases of severe illness, and about 250 000 to 500 000 deaths.” Whittling 10% off that number, in addition to the effects on pregnancy,  cardiovascular disease and productivity lost, seems a reasonable goal.  We go after influenza because of all the complications associated with the illness in addition to the almost unique morbidity and mortality the primary infection can cause.   We fret as historically influenza epidemics have killed millions and we do not want a repeat of 1919. Influenza often is so much more than a flu like illness.]

The harm side, the safety side, is understudied.

[Although numerous studies in a huge number of patients with a wide variety of underlying medical issues fail to reveal any consistant important or unusual complications of the vaccine and the disease is always worse than the vaccine.]

It’s very difficult to actually give you an accurate breakdown of the potential risk of the vaccine.

[Because it you stick to the plausible risks of vaccination based on plausible physiology there are not many. If you include being hit by asteroids as a potential risk, then it is hard to give an accurate breakdown.  After decades of giving the vaccine there are not any major risks, especially compared to the real and well documented risks of influenza. It is always about relative risks and benefits.  The vaccine is safer by many orders of magnitude than the disease.]

There is the potential risk to the mother, there is the potential risk to the unborn baby, there is the potential risk… the certain risk to the taxpayer. And that is something else that should not be forgotten.

[One gets the feeling from his tone that this really fries his bacon, spending HIS money on other peoples health care.]

There are very very few studies on pregnancy women and none of them are high quality.

[But all show benefit and no risk.]

So I was taught at medical school the less you do to pregnant women the better it is.

[That is such a disingenuous use of the naturalistic fallacy it makes my teeth hurt. The reason we do not have maternal death rates of sub Saharan Africa (as high as 1100/100,000 live birth), where they really do the less is better approach, is the multiple interventions to and for the mother and baby.]

This of course goes contrary to modern medicine.

[Yeah, lets go deliver out children in the third world.]

if you like which is more and more interventional, and more and more preventive between inverted commas (ed: I believe he was making air quotes).

As far as effects on the fetus are concerned of the vaccine, the second person, which is involved in this equation, I would be very very cautious, about vaccinating unborn babies even with dead vaccines like these ones.

[Despite all the data to show benefit? Sure, the data isn’t perfect, but hard to kill a few babies  and mothers for the sake of a perfect study.]

Of course live vaccines are out of the question for an unborn baby.

[That is the closest he gets to a declarative sentence.  As I read the interview over and over, I realized he insinuates a lot, but maintains deniability.  He never actually says don't get the flu vaccine.  I wonder in passing if he ever gets the vaccine. Although what little data there is suggests the live vaccine is safe for the fetus. <sarc>And wild influenza virus is so much better for mother and child</sarc>.]

Does that answer your question?

Null: Yes. Is it also the case when they are testing a vaccine should they also not have pregnant women and all the women with different diseases that would be required to take the vaccine included in the vaccine studies since when I read the literature I saw they were excluding the very people who would later be included in using it, to me that is a contradiction.

Jefferson: It’s not, it doesn’t necessarily have to be a contradiction because experiments, trials are quite artificial, in the way they are carried out, seldom are carried out in a perfect experiment, and there lies, in there lies some of the weakness of, of the design, of that particular design of a study, in as much as the more you select of the population, the less the results are application to the real population, so called reference population.

[That is always the difficulty in medicine: how does the results of a clinical trial apply to the patient you are treating. When I was a resident it seemed that all the studies for cardiovascular disease were done on old white smoking veterans. There are innumerable variables in influenza vaccination: the variability of the virus, the variability in the vaccine, the patient co-morbidities and (probably) the genetic ability of the patient to respond to both the vaccine and wild type infection. Seems daunting and will allow you to continuously quibble about the applicability of the results of a given  vaccine trial. On the other hand, generally speaking, exposure to antigen often leads to protective immunity most of the time in most people for most infections. It is more a matter of trying to maximize those effects in a heterogeneous population and why flu vaccination is better approached as a population effect than an individual effect.]

So some public health bodies have turned to commissioning what they call real life studies or studies on real life data. These are almost certainly observational studies, the vast majority observational studies. The difference between a trial and an observational study is that in a trial the researcher decides who gets the vaccine and who doesn’t or who gets the vaccine and who gets the control. In an observational study that decision has already been made. There observation study therefor is probably closer to reality. The only problem with that is the design itself is the carrier of problems. It is very very difficult to have good well designed prospective observational studies, and we do know that studies carried out in the United States in the 90′s, huge database studies, which showed the influenza vaccines effect were so biased as to give the wrong answer, to give an answer which was completely implausible

[I am not certain what he is referring to here. The protection of the vaccine from mortality when there is no flu circulating? I am suspicious that may be due to the reduction in deaths that follow any infection. Patients who are hospitalized for infections have a higher post discharge mortality rate than those who are admitted without infections and all infections seem to lead to an increase in MI, PE or stroke that risk  can persist for months after the infection. I wonder if that implausible effects of the flu vaccine are due to the lack of subsequent vascular events associated many infections.

Or he could be referring to the decrease in a fish at Pike Street Market.  Oh, I’ll take that study, that you very much.  The important question is whether the articles were submitted and rejected based on funding or were the government sponsored trials only submitted to lower impact journals and the editors of the high impact journals never even had the opportunity to be bribed, er, I mean, reject them.  We don’t know and for a someone whose complains about the conclusions of influenza  vaccine literature because of sloppy methodology and overstated conclusions making an insinuation based on a sloppy study with poor methodology and overstated conclusions does not add to his credibility. Relation of study quality, concordance, take home message, funding, and impact in studies of influenza vaccines: systematic review  nicely demonstrates that when there is an ax to grind how easy it is to give it a sharp edge with a touch of spin.

Dr. Jefferson does like to position himself as the rare pure soul in a sea of venality and corruption:

“Much has been said about the role of experts in advising policy makers on both seasonal and pandemic influenza. We know that some of them have been parsimonious with declaring their interests and their role as members of lobbying organizations which are financed by industry and some did not think it important to disclose pretty hefty industry funding of their institutions. We know that transparency is proably not taken very seriously by WHO. However, few people realize that even experts with no ties to industry or government civil servants have career motivations, especially if they make policy and evaluate its effects.

I’ll leave the description of how this works to Professor Philip Alcabes in his modern classic Dread: “We are supposed to be prepared for a pandemic of some kind of influenza because the flu watchers, the people who make a living out of studying the virus and who need to attract continued grant funding to keep studying it, must persuade the funding agencies of the urgency of fighting a coming plague”(15).

Before you start wondering how I can myself escape this kind of criticisms I would like to inform readers that 2 months before the hearing I circulated a note of activities and interests in which I disclose all that I can think are relevant to this debate. The note was sent to the Secreteriat and can be viewed by any member of the Commission. In addition I would like to remind you of what I have written and stated to the media countless times since 2004: beware of catastrophic predictions, stick to the scientific evidence: all the evidence, not just what supports your theories (16).”

Dr. Jefferson tends to torpedo the conclusions of his own work, taking modest efficacy of the flu vaccine and treatment in the Cochrane and other meta-analysis and making sure we know the glass is half empty, not half full.  Much of what he has published demonstrates modest flu vaccine efficacy, although he does his very best to muddy the water:

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…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.

[Attention.  Attention. This is the Pot speaking. The Kettle is black.  Not me. Just the Kettle. That is all.] 

The content and conclusions of this review should be interpreted in the light of this finding.

We identified one RCT assessing efficacy and effectiveness. Although this seemed to show an effect against influenza symptoms it was underpowered to detect any effect on complications (1348 participants). The remainder of our evidence base included non-RCTs. Due to the general low quality of non-RCTs and the likely presence of biases, which make interpretation of these data difficult and any firm conclusions potentially misleading, we were unable to reach clear conclusions about the effects of the vaccines in the elderly.

Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission. WARNING: This review includes 15 out of 36 trials funded by industry (four had no funding declaration). 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 favorable 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 light of this finding.

Influenza vaccines (especially two-dose live attenuated vaccines) are efficacious in children older than 2 years. Efficacy and effectiveness of the vaccines differed strikingly. Only two small studies assessed the effects of influenza vaccines on hospital admissions and no studies assessed reductions in mortality, serious complications, and community transmission of influenza. If influenza immunization in children is to be recommended as public-health policy, large-scale studies assessing such important outcomes and undertaking direct comparisons of vaccines are urgently needed.

Amantadine prevented 23% of clinical influenza cases (95% confidence interval 11% to 34%), and 63% of serologically confirmed clinical influenza A cases (95% confidence interval 42% to 76%). Amantadine reduced duration of fever by one day (95% confidence interval 0.7 to 1.3). Rimantadine demonstrated comparable effectiveness, but there were fewer trials and the results for prevention were not statistically significant. Both amantadine and rimantadine induced significant gastrointestinal adverse effects. Adverse effects of the central nervous system and study withdrawals were significantly more common with amantadine than rimantadine.
REVIEWER’S CONCLUSIONS:
Amantadine and rimantadine have comparable effectiveness in the prevention and treatment of influenza A in healthy adults, although rimantadine induces fewer adverse effects than amantadine.

No effect was shown for specific outcomes: laboratory-proven influenza, pneumonia and death from pneumonia. An effect was shown for the non-specific outcomes of ILI, GP consultations for ILI and all-cause mortality in individuals >/= 60. These non-specific outcomes are difficult to interpret because ILI includes many pathogens, and winter influenza contributes < 10% to all-cause mortality in individuals >/= 60. The key interest is preventing laboratory-proven influenza in individuals >/= 60, pneumonia and deaths from pneumonia, and we cannot draw such conclusions. The identified studies are at high risk of bias. Some HCWs remain unvaccinated because they do not perceive risk, doubt vaccine efficacy and are concerned about side effects. This review did not find information on co-interventions with HCW vaccination: hand washing, face masks, early detection of laboratory-proven influenza, quarantine, avoiding admissions, anti-virals, and asking HCWs with ILI not to work. We conclude there is no evidence that vaccinating HCWs prevents influenza in elderly residents in LTCFs. High quality RCTs are required to avoid risks of bias in methodology and conduct, and to test these interventions in combination.

But remember, I have given up on the Cochrane Group, which recently gave us:

Cochrane Database Syst Rev. 2012 Sep 12;9 Acupuncture for mumps in children. He J, Zheng M, Zhang M, Jiang H.

Abstract
BACKGROUND:
Mumps is an acute, viral illness transmitted by respiratory droplets and saliva. A number of studies published in China have suggested that acupuncture is beneficial for children with mumps but the literature reporting the benefits or harms of acupuncture for mumps has not been systematically reviewed.
OBJECTIVES:
To determine the efficacy and safety of acupuncture for children with mumps.
SEARCH METHODS:
We searched CENTRAL (2012, Issue 4), MEDLINE (1950 to April week 4, 2012), EMBASE (1974 to May 2012), CINAHL (1981 to May 2012), AMED (1985 to May 2012), the Chinese BioMedicine Database (CBM) (1979 to May 2012), China National Knowledge Infrastructure (CNKI) (1979 to May 2012), Chinese Technology Periodical Database (CTPD) (1989 to May 2012) and WANFANG database (1982 to May 2012). We also handsearched a number of journals (from first issue to current issue).
SELECTION CRITERIA:
We included randomised controlled trials comparing acupuncture with placebo acupuncture, no management, Chinese medication, Western medication or other treatments for mumps. Acupuncture included either traditional acupuncture or contemporary acupuncture, regardless of the source of stimulation (body, electro, scalp, fire, hand, fine needle, moxibustion).
DATA COLLECTION AND ANALYSIS:
Two review authors independently extracted data and assessed the quality of included studies. We calculated risk ratios (RR) with their 95% confidence intervals (CI) for the effective percentage and standardised mean differences (SMD) with 95% CIs for the time to cure.
MAIN RESULTS:
Only one study with 239 participants met our inclusion criteria. There were a total of 120 participants in the acupuncture group, of which 106 recovered, with their temperature returning back to normal and no swelling or pain of the parotid gland; the condition of 14 participants improved, with a drop in temperature and alleviation of swelling or pain of the parotid gland. There were 119 participants in the Western medicine group, of which 56 recovered and the condition of 63 improved. The acupuncture group had a higher recovery rate than the control group. The relative RR of recovery was 1.88 (95% CI 1.53 to 2.30). However, the acupuncture group had a longer time to cure than the control group. The mean was 4.20 days and the standard deviation (SD) was 0.46 in the acupuncture group, while in the control group the mean was 3.78 days and the SD was 0.46.There was a potential risk of bias in the study because of low methodological quality.
AUTHORS’ CONCLUSIONS:
We could not reach any confident conclusions about the efficacy and safety of acupuncture based on one study. More high-quality research is needed.”

A meta-analysis on one study on an intervention of magic. Pu-lease.  I think they are running out of topics to meta-analyze. Next they will do a  meta-analysis and systematic review of the written content on cereal boxes. And this is from Dr. Jefferson’s Group,  the Cochrane Acute Respiratory Infections Group. I know, guilt by association again.]

Null: Also, if there are almost 200 different infectious organism that can cause flu like symptoms, and there is no standardized testing and proper diagnosis for people when they go to the doctor or clinic to be treated for a flu like illness, then what are we to make of all the warnings given about the seriousness of a particular flu season and also the world health Organizations record at predicting which strains of flu should be used in a given years flu vaccine is rather dismal and then there are studies such as Danish study that those receiving a seasonal flu vaccine in 2009 were more likely to get infected with swine flu and Canadian studies by ?? and ?? seem to confirm this same finding. So even the predictions of the flu strains are frequently inaccurate and what good is the flu vaccine against other flu strains not in the formulation.

[It depends on what part of the flu antigens you develop a response to; as H1N1 demonstrated, some people may develop universal antibody.  I feel great sympathy for Public Health officials as they cannot win. Influenza is impossible to predict correctly.  If the season is bad and they don't call it in advance or of the season is bad and they predict a mild season, they are criticized.  dis-ease.]

Because in the middle ages they could not understand why these local epidemics came and went. Mainly benign, they are self limiting, they last a few days, and they are unpredictable.

[My understanding is that influenza was particularly bad in the era of poor nutrition and hygiene; its English name was the The genetic elements of influenza A viruses circulate globally in an extensive ecosystem comprised of many avian and mammalian species and a spectrum of environments. Unstable gene constellations found in avian species become stable viruses only upon switching to secondary hosts, but may then adapt and circulate independently. It may be desirable to think of influenza A viruses as existing and evolving in a large ecosystem involving multiple hosts and environments. Implications for understanding human influenza are discussed.” ]

It is an understudied, the real science behind this is understudied. It is covered in dogma, it is covered in public health marketing, and it is covered really in poor science as you pointed out. Very difficult to find good quality research in this area. It is not an easy area to research of course.

[I don’t really know what area he is talking about here. Flu spread? Vaccines? What does dogma have to do with 1789 flu outbreak?  Public health marketing?  It really gripes my cookies how he dismisses an enormous number of hard working professionals whose main goal is to prevent as many people as possible from dying from influenza and other diseases and an equally enormous supporting literature as dogma marketing.  But Dr. Jefferson knows better.]

And the influenza vaccine mutates its coat, changes its coat very frequently, so it’s a, it’s a running target, the (??) influenza virus. It’s a running target, it changes. And you are quite right, clinically it is impossible to tell an influenza like illness, what you call the flu, caused by influenza virus from that caused by any of the other agents.

Bear in mind Gary that some studies show that almost 40% of these episodes have no recognizable cause.

[So? What does that have to do with flu vaccine efficacy.]

So that may mean they are caused by microorganisms which we cannot culture, which we cannot grow, or we cannot recognize, or are unknown, or they may not even be infectious, they may be stress related,

[Stress causing fevers to 104, severe myalgias, headache, intractable cough and shortness of breath?!?!?!?!? Glad he is not my GP.]

so it is a completely understudied area. The good science of it. The bad science part, well there’s tonnes of bad studies out there that show whatever they want to show.

[By that criteria all of medicine is understudied.  Our knowledge of the causes of respiratory infections grows yearly and I suppose if we to devote the entire NIH budget to its investigation all would be clear.  That last part "tonnes of bad studies out there that show whatever they want to show" is again disingenuous and dismissive of a preponderance of data that shows results that Dr. Jefferson doesn't agree with, including the conclusions of his own work.]

Null: Well, I appreciate your coming on and sharing this insight with us today and we really support all your good efforts because you and your group over in Rome and Italy, you are not motivated by money you get from pharmaceutical industries. You just tell us the truth and what you are telling us gives us a reason for pause and to demand more independent, quality scientific research

[Such as the quality scientific research, free of financial incentive, that  Mr. Null has demonstrated for his products, including the effects of I read the Atlantic article about Dr. Jefferson, I was struck by the section that mentioned he was ostracized at meetings, eating alone:

Among his fellow flu researchers, Jefferson’s outspokenness has made him something of a pariah. At a 2007 meeting on pandemic preparedness at a hotel in Bethesda, Maryland, Jefferson, who’d been invited to speak at the conference, was not greeted by any of the colleagues milling about the lobby. He ate his meals in the hotel restaurant alone, surrounded by scientists chatting amiably at other tables.

and I thought, what a bunch of bastards. I spend lots of time with people with whom I disagree and we have fun arguing back and forth.  Just because we disagree does not mean we can’t enjoy a good conversation and be civil.

Now I am not so certain. The interview suggests a conspiracy theorist  who has a narrow viewpoint and ignores or misstates his own studies and the studies of others and prefers a simple message to the complexity of influenza and its many complications. What comes across in his interview, and in his written, and presumably carefully considered oeuvre, is buckets of anti-influenza vaccine bias; someone who has an opinion first which he defends with the narrowest of data second.   He was interviewed in the appropriate venue after all.

PS

As I was writing this entry the Secret kicked into high gear in its spooky way yet again. Our editor received the folllowing letter:

I am the Social Media Marketing Manager here at Progressive Radio Network which is the #1 Progressive Internet Radio Station. We currently have a very popular Health and Nutrition Show on the network called “The Gary Null Show”. It is hosted by Gary Null who also owns his own Power Foods site (www.garynull.com). He also has numerous award winning documentaries and articles. We would like to get the show featured on your website if possible.

You ask, the Universe provides. Creepy.

*I have been trying to work influenza into the title of the Ken Kesey book for years.

 

Posted in: Clinical Trials, Epidemiology, Public Health, Science and Medicine, Science and the Media, Vaccines

Leave a Comment (51) ↓

51 thoughts on “One Flu Into the Cuckoo’s Nest*

  1. Janet says:

    Yeah, but who listens to Gary Null except the already convinced? Even before I had a computer or this blog existed, I turned him off when he came onto the little independent station I listened to on my little (actually rather big) island in the Pacific Northwest. He was so damned belligerent and cranky.

    Thanks anyway for explaining so much–and for exposing Jefferson, who I was unaware of (of whom I was unaware?).

  2. nybgrus says:

    Thanks for this Dr. Crislip. It is always useful information to bring to the table both for patients and amongst my colleagues and superiors.

  3. mousethatroared says:

    So our family all got the flu shot this year. In the last couple of weeks my daughter got a little sick for one day. Achy, nausea, no fever. I got very achy, fatigued with the lingering cough, but no fever. My son got a fever of 101-104, achy, cough, for three days, extremely sick the first day. My husband got food poisoning or similar, instead.

    So here’s my question, They are saying this year’s vaccine is 68% effective. Is that 68% of people avoid the flu or you only get 42% sick? or a combination of both?

    Not that I’m complaining. Okay, maybe I’m 42% complaining.

  4. nybgrus says:

    @mouse:

    My understanding is that 68% effective refers to the population statistic. This number is necessarily inaccurate since the only way to truly get the efficiency is to compare rates of infection in vaccinated vs unvaccinated populations (which is also inaccurate even post flu season, since we can only use estimates based on who is actually tested). The 68% is a preliminary number based on, unless I am mistaken, a representative sampling of what flu strains are being noted early in the season compared with what flu strains the vaccines actually vaccinate against.

    So in other words they would get samples and determine there are (made up numbers) 120 different strains of flu detected so far. Of those, 100 of them account for 98% of the flu cases documented. Of these 100, 68 of them are found in the flu vaccine. It is necessarily impossible to determine who didn’t get the flu who otherwise would have without the vaccine since we cannot accurately test exposure that fails to lead to infection. So this is a very simplified version with made up numbers but I believe is a reasonably accurate approximation.

    Also bear in mind that as Dr. Crislip pointed out, different people with respond differently to the vaccine both by factors of genetics and by random chance. When the immune system is presented with an antigen the “antigen presenting cells” or APC’s (which are also called the “professional” cells) chop of the antigen randomly into small sections and then present these to the B cells down the line. The B cells use these randomly chopped up bits to then randomly generate antibodies, and the ones that “fit” well are kept and those that don’t are discarded (the how of this is probably to complicated and boring for this discussion, but uses the awesome term “somatic hyper mutability”). So depending on random chance, you may develop strong antibodies against bits of the virus that are more or less effective at actually stopping it. Of course you don’t just produce 1 antibody and call it a day – there are a range. And how big this range is and how well it fits is partly chance and partly genetics.

    Lastly, flu-like illness doesn’t mean flu. None of you may have actually had the flu. Or only one. Or all. It could have been different strains between you all (though that is less likely, it is certainly possible). And if it was the same strain your husband could have formed “better” antibodies than your son, by pure chance, bad genetic luck, or likely both.

    But population statistics don’t directly translate to individual people. That is called the “ecological fallacy.” So if the vaccine is 68% effective that doesn’t mean each person given the vaccine has a 32% (not 42, but it just a simple math error and understood) of getting the flu and a 68% of not getting it. It becomes vastly more complicated at that point requiring taking into account those individual differences I described above, as well as the prevalence of flu in general and in certain strains in specific within the community of the person in question, and the vagaries of transmission and exposure.

    Sorry, probably more detalied than you were looking for, but I hope it is both comprehensible and helpful.

    BTW – total non sequiter side note, but perhaps you’d be proud of me: I have begun attempting “art.” LOL. I have painted two paintings in acrylic (which is the first time I have ever used acyrlics and quite literally the most painting I have ever done in my life prior to this combined) and am currently working on a large paper mache and mixed media art piece (which is my first time ever doing anything with paper mache in my life). It is proving both challenging and fun. The paper mache piece is by far the longest and most intricate art project I have ever done – so far it has taken me 5 days (mostly because of drying time) and I am only about 1/3 done.

  5. Science Mom says:

    I would like to caution that we keep Jefferson the man (having dubious relationships with unsavoury anti-vaxx loons and making very stupid comments) separate from his work with the Cochrane Collaboration which has also been replicated by the CIDRAP group this past year. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2811%2970295-X/abstract and http://www.cidrap.umn.edu/cidrap/files/80/ccivi%20report.pdf

    While lead author Dr. Osterholm is certainly not saying, “don’t get vaccinated”, he is refreshingly honest about the lack of evidence that has driven U.S. influenza vaccine policy and identifies numerous inaccurate statements that were used to justify ACIP policies. http://query.nytimes.com/gst/fullpage.html?sec=health&res=9F07E4DB1031F935A35752C1A9649D8B63

    I think we do ourselves a great injustice and risk our own credibility by having a blind-spot with regards to the effectiveness of current influenza vaccines and the lack of evidence for policy-makers. Continuing to deny the vastly overstated benefits of influenza vaccines and opinion-based vaccine policies will continue to be fodder for anti-vaxxers.

  6. mousethatroared says:

    Ha – nybrgus, I knew it was hazardous attempting to do math in public. Glad you got the idea.

    I did kinda get that the 68% effectiveness didn’t apply to individuals, but I was curious where the number came from. Thanks for the explanation.

    Congrats on painting and mixed media endeavors! I generally work in acrylics, mixed media…which I should be doing right now instead of reading SBM. If you are working small and you get frustrated with the paper mâché process, you should try paper clay. It’s fun to work with, air dries and is paintable. But, it’s a bit expensive, so not great for large work.

    If you ever feel like it, post photos somewhere. I love seeing people’s artwork.

  7. nybgrus says:

    Always a pleasure.

    As for the artistic endeavors… it certainly won’t become something I do regularly or become quite proficient in (at least not the foreseeable future), but it is fun to give it a go. The paper mache piece is for a costume I am making. I’ll post up a few images when it is complete. In fact, I am know going to go put on the next layer of mache. Then after drying will be the first layer of base paint, followed by a few other layers for color effects, then cutting out the various holes and slots necessary to make it work (it will be a helmet, essentially) and then wiring up all the lights that will be embedded it in, and then any last touches.

  8. Mark Crislip says:

    I think we do ourselves a great injustice and risk our own credibility by having a blind-spot with regards to the effectiveness of current influenza vaccines and the lack of evidence for policy-makers.

    I dont think there is a lack of evidence, but perhaps a lack of gold standard evidience, and the evidence there is all points to modest efficacy. Whether good enough to warrent the spending of time and money for public health is a judgement call where I would vote yes. At what point to you have information to act or do you wait until there is perfect inforamtion. They are intersting problems.

    As to overselling the vaccine? It is difficult. When writing patient material we are told to write to a 6th grade reading level. One of our faculty has a particular interest in health literacy and it is a sobering talk on how little many people understand about medicine and health.

    Re: the Minn paper and Osterholm. He doesn’t say anything new that hasn’t been discussed in the blog or is known.

  9. Todd W. says:

    I always get a bit of a kick out of people who complain about how the flu vaccine doesn’t prevent influenza-like illnesses that are caused by something other than influenza virus.

    As for Jefferson, he may do decent science and adhere to journal guidelines for not overstating the data in his published papers, but this performance on Null’s show? He does a great disservice to public health.

  10. WilliamLawrenceUtridge says:

    I think we do ourselves a great injustice and risk our own credibility by having a blind-spot with regards to the effectiveness of current influenza vaccines and the lack of evidence for policy-makers. Continuing to deny the vastly overstated benefits of influenza vaccines and opinion-based vaccine policies will continue to be fodder for anti-vaxxers.

    The evidence seems to point that on a risk-benefit basis, vaccination is warranted. On a cost-benefit basis, vaccination is questionable but in aggregate leans towards being warranted (more so with a national health service of some sort since the costs and benefits can accrue more easily rather than being shouldered by individuals or institutions). And from a scientific literacy perspective (both the ability of citizens to understand the controversies, and the trust the public has in vaccination in general when faced with such a murky issue) you really are stuck between a rock and a hard place. The public wants to hear “X is good for you” so they know to do X. They want X to be 100% safe and effective. They don’t want X to affect their taxes. “Yes-but” plays quite poorly. Giving time to the complexities of a genuinely complex issue grants credibility to the loons and liars who have no interest in being nuanced. But oversimplifying means you lose, horribly, if something is actually wrong (hello narcolepsy, please come in and destroy all support for influenza vaccinations).

  11. mousethatroared says:

    @nybrgus – a helmet like construct with lights…I’m liking the sound of that. I look forward to seeing the results.

  12. rork says:

    Thanks so much for the small review of 2009 flu overwhelm, with stuff like:
    “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. ”
    The shocking part for me is how many people tell stories that recall there being essentially no problems. It’s sometimes held up as proof that vaxing is overhyped. We were so close to much too much it was scary, and that’s just about what lots of experts had predicted.

  13. Harriet Hall says:

    How could you stand to listen to the whole thing, much less transcribe it? Thanks for sacrificing yourself for the cause. I worry about your blood pressure.

  14. Mark Crislip says:

    Given my typing skills it took me almost three hours of listening and re-listening for a 15 minute interview.

    The things I do for SBM

  15. Scott says:

    The thing I learned from this post, that’s very interesting indeed, is this bit:

    We use flu like illness as a surrogate since it is not practical to test everyone for influenza… We go after influenza because of all the complications associated with the illness in addition to the almost unique morbidity and mortality the primary infection can cause.

    Seems to be saying that not all “flu like illnesses” are equal in their ability to produce morbidity and mortality. Influenza has much more than most, so going after it accounts for a greater proportion of morbidity/mortality than the proportion of “flu like illness” it comprises. Hence, simply arguing that most “flu like illness” isn’t influenza misses the point, because preventing “flu like illness” isn’t the main objective; preventing the more severe complications is, and those ARE disproportionately due to influenza.

    Am I reading that right? If so, it’s a pretty compelling argument IMO.

  16. nybgrus says:

    The things I do for SBM

    When I worked as an ER tech for 3 years before starting med school we had a very elderly lady on whom we desperately needed a urine sample. At least I was convinced by physicians I trusted that this was the case, both from a medical and legal standpoint. At one point she finally had the urge but it was very sudden and I happened to be nearby. In her haste she made it clear she would not and could not hold the cup. So I went in the bathroom with her (at her request and with consent) and held the cup between her legs. Some of it made it in the cup. Most of it ended up on my arm. The glove I wore was completely useless.

    For the life of me I do not remember the exact circumstances or why she was even there (this was 5+ years ago) and I did not know enough medicine at the time to evaluate how critical that sample was. But I was convinced enough apparently.

    The things I have done for medicine. LOL.

    @mouse: Yes. It is for costumery with fiancé and friends. The theme: bioluminescent animals. The final dry before paint and lighting is underway!

  17. mousethatroared says:

    @nybrgus – costumery? You all just come up with a theme and make costumes? How wonderful!

    Hm, I’ve been peed on alot, but since it was only my children, I don’t think it’s fair to claim it as a sacrifice to science or anything else…possibly an investment in my ability to blackmail those same kids into coming home on time when they’re teen-agers.

    I’m also very impressed that Mark Crislip transcribed that interview. We should buy him a drink. He probably needs it after that.

  18. DugganSC says:

    I’m assuming that “I don’t influenza” should read “I don’t get influenza”?

    :) I’ve passed this on to my friends on Facebook (and all of the other people on my list). Interesting to hear that there are more cases overall, if less deadly.

  19. nybgrus says:

    @mouse:

    We have a reason for the costumes, but yes we came up with a theme and so far at least 5 or 6 are participating.

    As for Dr. Crislip transcribing… yes indeed. Though I would have tried to parse it through a voice recognition program first and then fixed the errors to save time. Though that could certainly have led to more trouble than it was worth.

    If I make it to Portland and/or if we meet at a conference (TAM, lets say since I am definitely going and have already booked my hotel room) a beer is certainly in order. I’m partial to really, really robust IPA’s. Megatons of hops exploding in my mouth. Alternatively a silky smooth stout like Tatonka Stout or Old Rasputin is always welcome.

  20. Science Mom says:

    I dont think there is a lack of evidence, but perhaps a lack of gold standard evidience, and the evidence there is all points to modest efficacy. Whether good enough to warrent the spending of time and money for public health is a judgement call where I would vote yes. At what point to you have information to act or do you wait until there is perfect inforamtion. They are intersting problems.

    Thanks for the response Dr. Crislip but I have to beg to differ. There is overall modest effectiveness in older children and adults <65 years old (and highly variable from year to year depending upon strain match) and no more efficacious in the outside age groups (children less than 2 years old with TIVs) than placebo. The argument is not perfect information (well at least from people like me) but rather solid information that is the basis for a reasonably unassailable policy decision.

    ACIP policy is at best based upon wishful-thinking and flimsy evidence and they have set up an impossible situation for determining vaccine effectiveness for all age and risk groups. Since they have set the policy that these groups should receive vaccination, it is unethical to intentionally withhold vaccination for the purpose of research. We are left with (maybe) data generated in other countries but with very poor generalisability to the U.S. population due to differences in vaccines, healthcare access and data collection and testing methods just to name a few. I'm not sure that revoking policy is the answer but revising it to reflect the current body of evidence and the appropriate risk communication sure are as well as designing robust studies to support recommendations.

    As to overselling the vaccine? It is difficult. When writing patient material we are told to write to a 6th grade reading level. One of our faculty has a particular interest in health literacy and it is a sobering talk on how little many people understand about medicine and health.

    I think risk communication is a different matter than what I am addressing unless you are suggesting that it is all right to misrepresent the evidence to “sell” the vaccine in which case I would strongly disagree.

    Re: the Minn paper and Osterholm. He doesn’t say anything new that hasn’t been discussed in the blog or is known.

    I searched the blog and did not find a post dedicated to the CIDRAP meta-analysis although found some comments in other posts from rather colourful characters. It may be known but it doesn’t seem to have been confronted but rather dismissed. I personally find myself in the uncomfortable position of being on the “same side” as anti-vaxx nuts even if for rational reasoning instead of blindly whacking about with a stick and finally hitting something and at odds with people who I have a lot of respect for. If we are to cultivate public confidence in health policies, then it needs to be evidence-based and not opinion-based. And the over-arching problem with how flu vaccine policy has been decided, information disseminated and public resistance to vaccines will only serve to erode public confidence that will lead to less vaccine uptake and less confidence in future recommendations.

    @ WilliamLawrenceUtridge, I thank you for your thoughtful comments too and hope that my responses address yours as well.

  21. Mark Crislip says:

    sciencemom: I wonder if we are talking about the same endpoints. You appear to be refer to stopping a given individual from getting the flu.

    I refer to all the information that suggests vaccine benefits are more widespread and prevents spread to newborns, decreases heart attacks, decreases hospitalization, decreases spontaneous abortions, decreases hospitalizations, decreases days off work etc. I find the population data compelling. But I am referring to all the endpoints of vaccine benefit.

    As an example, I find studies such as these very compelling despite the flaws

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2573914/?tool=pubmed

    which is representative of a literature that shows a consistant population benefit.

    It occurs to me I do not know of an example where, say, the CDC is overselling the flu vaccine, I tend to spend my time in the primary literature and not the second hand sources. It would make an interesting paper on misinformation by the CDC. Got some examples for me? It would make a good post.

    My read of the Osterholm paper: flu vaccine is ok, has some protection, the data isn’t great, we need better vaccines and better studies. That is not news to me.

  22. Mark Crislip says:

    As I was driving home I actually listened to a commertial for the flu vaccine. They said “getting the flu vaccine significally reduces your risk for becoming ill.”

    I do not think that is an unreasonable statement, although I could follow it with several dozen caveats.

  23. Science Mom says:

    sciencemom: I wonder if we are talking about the same endpoints. You appear to be refer to stopping a given individual from getting the flu.

    Not at all.

    I refer to all the information that suggests vaccine benefits are more widespread and prevents spread to newborns, decreases heart attacks, decreases hospitalization, decreases spontaneous abortions, decreases hospitalizations, decreases days off work etc. I find the population data compelling. But I am referring to all the endpoints of vaccine benefit.

    Therein lies the problem; there is such paucity in the data that we can only estimate that the vaccine has a modest effect (at best) in some populations some years with the higher quality data available.

    It occurs to me I do not know of an example where, say, the CDC is overselling the flu vaccine, I tend to spend my time in the primary literature and not the second hand sources. It would make an interesting paper on misinformation by the CDC. Got some examples for me? It would make a good post.

    I think that’s a capital idea. If you go to the CCIVI Report: http://www.cidrap.umn.edu/cidrap/files/80/ccivi%20report.pdf and go to the “Health Promotion Activities Related to Influenza Vaccine Use” section starting on (report) page 58, you will read many examples of this and citations are included.

  24. Amalthea says:

    Dr. Crislip said: “As I was driving home I actually listened to a commertial for the flu vaccine. They said “getting the flu vaccine significally reduces your risk for becoming ill.”

    This is why I never bothered to get a flu shot until last November. I’m one of those people who’s body fights off flu pretty well all by itself without help. Fewer illnesses, shorter duration and much milder symptoms if affected…. A shot didn’t seem needed. Then I finally learned that part of the reason was actually to reduce the transmission of the disease via asymptomatic people and I realized that since I work among the public this was a problem so I got a shot early this season.

  25. starskeptic says:

    Testing Flu using PCR is an expensive way to go about it – is that necessary for your institution?

  26. Harriet Hall says:

    “I’m one of those people who’s body fights off flu pretty well all by itself without help. Fewer illnesses, shorter duration and much milder symptoms if affected….” Famous last words…

  27. carsonbro says:

    Are you suggesting the evidence from Udell’s study regarding the influenza vaccine protecting against heart disease is credible? It is far too early to promote that benefit and therein lies the problems with overpromoting this vaccine only to later have information to the contrary revealed and find the public trust eroded for this complicated vaccine. For instance, I could counter that argument with a study out of Mainz University Medical Center in Germany that found a cardiovascular risk to influenza vaccination. Animal experiments and epidemiological data suggested that over-stimulation of the immune system may accelerate atherogenesis and all the complications it brings.

    Bhakdi S, Lachner K and Doerr H-W. Possible hidden hazards of mass vaccination against new influenza A/H1N1: have the cardiovascular risks been adequately weighed? Med Microbiol Immunol 2009, 198, 205-9.

  28. mousethatroared says:

    nybrgus “We have a reason for the costumes, but yes we came up with a theme and so far at least 5 or 6 are participating.”

    Oh, “you have a reason” you’re not robbing a bank. Are you? :)

    IPA – Always a good choice in my book.

  29. nybgrus says:

    AP Reuters –

    A group of bandits dressed as biolumiscent animals made a daring bank heist today by distracting the patrons, tellers, and security guards exploiting the need for all animals to be entranced by glowing things in what will undoubtedly become known as the first bank heist pulled off based on ancient phylogenetic similarities rooted in evolutionary biology.

    One security guard was questioned on his experience and asked if he was afraid of the gang to which he responded, “Ooooh… pretty…. lights….”

    A bank customer was noted to say that he would happily give up his money again to see the pretty lights once more.

    As for IPA – my fiancé absolutely detests it. Says it tastes like perfume to her. Black swan level proof positive that nobody is perfect.

  30. OneThree Athlete says:

    Does anyone know of a resource that tells which flu strains are circulating where? For Example, A/Victoria/361/2011 (H3N2)-like virus has been the prominent virus found in St. Louis hospitals. Something that puts together geographic locations with specific strains.

  31. mousethatroared says:

    @nybrgus – Perfect, LOL!

  32. nybgrus says:

    @athlete:

    the CDC has the latest on this season’s strains.

    Google has a trend map that is pretty cool.

  33. Narad says:

    For instance, I could counter that argument with a study out of Mainz University Medical Center in Germany that found a cardiovascular risk to influenza vaccination.

    That’s not a “study,” it’s an editorial. (Also, don’t do this: “We also thank Monika Wiedmann for subperb secretarial assistance.”)

  34. pharmavixen says:

    Dr. Jefferson makes reference to Dr. Philip Alcabes. So I asked Dr. Google:

    http://www.philipalcabes.com/2013/01/against-universal-flu-immunization/

    “Public health benefit?

    No. Over the past twenty years, flu-vaccine coverage — the proportion of the population that is immunized — has been going up progressively. But flu hospitalization and mortality rates have been basically constant. If mass immunization had any public health value, those rates should go down as coverage goes up.”

    (No link to this study was provided, and I haven’t looked for it thus far.)

    Dr. Alcabes has a phD in infectious diseases epidemiology, according to the site.

    Surfing his site, I thought he sounded maybe a bit woo-y, like the serious consideration he gives to the idea that Andrew Wakefield was the victim of a witchhunt, and his use of the term, “Vaccine crusaders.”

    And there’s this article here:

    http://www.philipalcabes.com/2011/04/profiting-from-preparedness/

    “Don’t miss Helen Epstein’s brilliant exposé in the latest issue of The New York Review of Books. She shows how the profit motive shapes the “preparedness” industry — worth $10 billion worldwide in 2009 (the year of the Flu Pandemic That Wasn’t).

    I’ve covered the profit-motivated thinking behind vaccine recommendations generally and specifically with regard to flu immunization. Epstein’s main interest is in the role of pharmaceutical companies in promoting oseltamivir (Tamiflu®) and other neuraminidase inhibitors as public health responses to flu fears. Her story features the brilliant work of Tom Jefferson and colleagues, and the shady behavior of the global biotech firm Roche in trying to block Jefferson et al.’s efforts to investigate the safety of neuraminidase-blocking agents.”

    Interesting.

  35. pharmavixen says:

    @ Science Mom: the benefits of the flu vaccine are okay-ish at best, but they are there. And the risks of the vaccine are extremely tiny; in fact, the risk of getting Guillane-Barre syndrome from the flu are five times greater than getting it from the vaccine. Granted the benefits aren’t unequivocal like the smallpox or polio vaccines, but the risk-benefit analysis favours flu shots.

    Nit-picking the evidence = delaying or avoiding the flu shot = spreading it to vulnerable close contacts, who become seriously sick or die. Sure, a 67% effectiveness is pretty darn unimpressive, but it’s not nothing.

  36. BillyJoe says:

    I’ve only ever attended one fancy dress party. The idea was to dress up as someone famous in popular music. For some reason I chose Maurice Gibb – yeah, not very famous! I think I chose him was because I had acquired (but never worn) a hat and sunglasses similar to what he usually wears on stage. Also I had a beard at the time. The resemblance was so striking that I was judged the winner!

    Here I am: http://www.last.fm/music/Maurice+Gibb/+images/318770

    Well, it’s Maurice Gibb, but it could be me dressed up as him.
    Anyhow, looking forward to seeing you in your paper mâché helmet. :)

  37. WilliamLawrenceUtridge says:

    Animal experiments and epidemiological data suggested that over-stimulation of the immune system may accelerate atherogenesis and all the complications it brings.

    If the argument is that the vaccine “overstimulates” the immune system, that seems flawed. The dose is tiny, compared to what you get from being actually sick with influenza, it doesn’t seem like the tiny amount of antigen in the shot would be “overstimulating”. If this is the case, once again the actual influenza virus would logically seem to be more dangerous than the much smaller dose (and much smaller immune system activation) of the vaccine.

  38. mousethatroared says:

    @WLU – When considering vaccination and “over stimulated” immune system, It might be useful to look at the research in vaccines with Folks with RA and Lupus.

    Here’s a link to an article about a couple of newer studies. I’m sure the original studies can be tracked down from there if someone wished.

    http://www.arthritistoday.org/conditions/more-conditions/flu-shot-side-effects.php

    Overview “9/16/11 Two recent studies show that flu vaccines are effective and protective in most people with RA and lupus, while causing little to no disease flare. The autoimmune diseases and some medications taken to suppress inflammation and the immune system may decrease the amount of protection provided by from the vaccine, the protection that is gained creates an important margin of safety for avoiding the flu and the potentially serious complications that can come from it.”

  39. mousethatroared says:

    The above is actually addressed to anyone, but since I picked up the conversation from WLU’s comment, I wanted to note that. :)

  40. Science Mom says:

    @ Science Mom: the benefits of the flu vaccine are okay-ish at best, but they are there. And the risks of the vaccine are extremely tiny; in fact, the risk of getting Guillane-Barre syndrome from the flu are five times greater than getting it from the vaccine. Granted the benefits aren’t unequivocal like the smallpox or polio vaccines, but the risk-benefit analysis favours flu shots.

    Thanks pharmavixen; I’m not disputing that. I don’t care for the way that policy has been implemented nor the “sales job” for promoting flu vaccine uptake. I could be wrong of course but I can’t help but wonder if blind acceptance of poor-quality studies and recommendations based upon those hasn’t actually hindered new vaccine development. And that would be a shame.

  41. Calli Arcale says:

    “So I was taught at medical school the less you do to pregnant women the better it is.”

    I was wondering how long it would take him to backpedal on his claim that pregnancy is a totally natural condition and so a pregnant woman is a healthy adult and you shouldn’t treat them special because they’re pregnant. Predictably, it’s as soon as it involves giving them a treatment. For centuries (and throughout much of the world still today), women were isolated and kept out of leadership roles on the basis that they can get pregnant, and you have to be gentle with pregnant women. Funny how it’s easy for some people to accept doing *nothing* to pregnant women than *something*. The sin of omission is so easy to forget….

    If a pregnant woman is a healthy adult with nothing special to fear from the flu, why is she not a healthy adult with nothing special to fear from the influenza vaccine? Why does he change his mind so dramatically here? Maybe because he’s a male chauvinist who thinks pregnant women should be tough and suck it up and simultaneously kept out of “strenuous” roles for the sake of their wombs, but I don’t actually think so. I think it’s because of context. In the first use, where he argues pregnancy is not a special condition, this is because he wants to argue that influenza is no big deal and so we don’t need to vaccinate against it, so arguing that pregnancy isn’t anything special is important, so he doesn’t have to look at reports of miscarriages and maternal deaths and premature babies. In the second use, it’s because he wants to argue that vaccination is dangerous, so suddenly pregnancy being special *is* important, and he *does* want to look at miscarriages and maternal deaths and premature babies.

  42. Alia says:

    While I don’t deny that flu vaccine is safe, it does occasionally have unpleasant side effect. The only time my mother got it (being a retired nurse, rather science-based and definitely pro-vaccine), her organism responded with very high fever (above 39 C) and splitting headache, so she decided not to repeat this experience. But that’s OK, being retired, she can avoid going out into crowded places during the height of flu season and everyone in our family gets the vax, in part to protect her.
    Me, I seem to be one of those lucky individuals for whom the vaccine works. When I was younger, I used to get the flu every two years or so. Since I started getting the vax about 10 years ago, no flu. And I work in a big school, 600 studens, 70 teachers and other staff, so it would be very easy to catch it. Of course, I do get colds and once I even had pharyngitis, but that’s totally different stuff.
    What surprises and saddens me is that most of my colleagues do not believe in flu vaccine. They look at me like I’m crazy to poison myself with the vaccine – and then they get down with flu and go on two weeks’ sick leave.

  43. WilliamLawrenceUtridge says:

    While I don’t deny that flu vaccine is safe, it does occasionally have unpleasant side effect.

    Particularly with something like influenza, so easy to confuse with another illness, so many confounds, this is were randomized controlled trials are needed. Were the side effects from the vaccine? Where they from the ‘flu virus itself? Were they from neither? And would your mother’s reaction have been better or worse if exposed to the ‘flu without the vaccine? It’s pretty impossible to know. And overall – when large numbers of people are involved, who gets more adverse reactions, and in aggregate are the reactions worse for ‘flu or vaccine? Anecdotes are incredibly compelling, the scientific response of “most people don’t get really sick but some do” is unsatisfying. It would be nice to see a comparison of the adverse reactions of a large number of people to the vaccine and the ‘flu to see which are worse.

  44. mousethatroared says:

    @BillyJoe – The first concert I ever went to was the BeeGees. My mom took me and a friend. We thought they were totally cool…had the Tiger Beat posters to prove it. No link needed to show me what Maurice Gibb looks (looked) like. :)

  45. mousethatroared says:

    ^^My poor mom. She was such a good sport.

  46. Narad says:

    We thought they were totally cool…had the Tiger Beat posters to prove it.

    Not as bad as having Tiger Beat posters of… the Bay City Rollers.

  47. Alia says:

    @WLU – I agree with you in that it’s hard to determine what is worse, side effects from vaccine or flu. The problem is, my mother is elderly, which means her response to the vaccine will probably be lower anyway. And I really don’t have the heart to tell her “You should try the vaccine again this year, perhaps it won’t be as bad”, because the only time she got it, she suffered. So we all vaccinate around her and she tries to avoid infection.

  48. BillyJoe says:

    Michelle,

    My first was Led Zeppelin. Or it might have been Pink Floyd
    The Bee Gees are cute though.

  49. Moebius says:

    And another:

    http://c2cjournal.ca/2013/01/volume-7-issue-1-quacks-and-conspiracies-the-undermining-of-science-and-your-health-2/

    Some Canadian newspapers are catching on. I like to think my letter to one about a credulous article on psychics may have had some influence.

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