Oct 21 2011

Fear Mongering the Flu Vaccine

In a recent article in The Canadian, journalist Anthony Gucciardi trots out long discredited anti-vaccine canards in the guise of actual journalism. The piece is poorly researched and resourced, blatantly biased, and amounts to little more than irresponsible fear-mongering about the flu vaccine.

Gucciardi writes:

Each dose of flu vaccine contains around 25 micrograms of thimerosal, over 250 times the Environmental Protection Agency’s safety limit of exposure.

Mercury, a neurotoxin, is especially damaging to undeveloped brains. Considering that 25 micrograms of mercury is considered unsafe by the EPA for any human under 550 pounds, the devastating health effects of mercury on a developing fetus are truly concerning.

Everything Gucciardi wrote is either outright factually wrong, or incomplete in a way that makes it highly misleading.

First – some forms of the flu vaccine (the multi-dose vials) do contain thimerosal, with 25 mcg of ethylmercury. But there are also many flu vaccines that contain no thimerosal and no mercury, because they come in single-dose vials and don’t require the preservative. Here is a list of all of the approved flu vaccines – you can see that eight of the vaccines listed have zero mercury, one is listed as having <= 1 mcg, and four are listed as having about 25 mcg.

I can see no reason why Gucciardi would have missed this fact – it’s almost as if he wants to scare his readers away from vaccines in general.

What about for those flu vaccines that do contain 25 mcg of mercury? Does this really exceed the EPA limit for safety? In a word, no, but this canard has been popular among anti-vaccine activists for years who, very much like creationists, would never abandon a useful argument simply because it’s factually incorrect.

First, the EPA limit is for methymercury, not ethylmercury, which is the form found in Thimerosal. Methylmercury is known to be much more toxic than ethylmercury. In addition ethylmercury (half life about a week) is cleared from the body much more quickly than methylmercury (half life about 1.5 months). Further, infants excrete mercury more efficiently than adults. The EPA safety limits are based upon the more toxic form of mercury, with a 10 fold built in safety buffer in case some people are more susceptible to mercury toxicity than others.

But even worse, Gucciardi completely misrepresents that nature of the EPA limits (the reference dose, or RfD, for methymercury is 0.1 mcg/kg). They are based upon safe daily consumption for life (the EPA uses 75 years as life-long consumption).

So Gucciardi confuses the EPA limit for daily lifelong consumption with one time or annual exposure. This is a pretty basic error, and it has been pointed out numerous times easily found on the internet.  Not content with the errors he has made so far, Gucciardi takes it up a notch:

The EPA’s safety limit of mercury exposure is being exceeded by over 250 times each shot. In addition to a number of other ‘recommended’ vaccines, flu shots are dished out each year to the public, meaning that this exposure increases to 250 times the limit each year. Over a 10 year period, it is possible to exceed the limit by 2500 times simply by receiving a yearly flu shot.

There is no doubt that Gucciardi is interpreting the daily limits as if they were a lifetime limit. It is not surprising, however, as he cites only secondary anti-vaccine sources, and not primary sources, for his information. He is, in essence, regurgitating anti-vaccine propaganda as if it were journalism.

Gucciardi bills himself as an “accomplished investigative journalist” but he has demonstrated here a combination of gross incompetence and extreme bias. In fact, he is a “natural medicine” advocate who has an anti-establishment medicine agenda. In other words, he is an activist masquerading as a journalist.

For good measure Gucciardi throws in some more anti-vaccine propaganda. To show how toxic mercury is he cites studies where workers exposed frequently to elemental mercury vapor developed toxicity. This has no relevancy, however, to thimerosal exposure. No one denies that mercury in high enough dose is toxic. But different forms and different doses have different toxic potential. Gucciardi chose studies that are as different from thimerosal as possible – acute exposure to inhaled elemental mercury vapor over a long period of time by workers. This tells us nothing about the effects of ethylmercury in some flu shots – but it can be used to scare the public.

Gucciardi also ignores the copious epidemiological evidence that shows a lack of correlation between thimerosal exposure and any adverse outcome, including autism. This evidence includes the fact that after thimerosal was removed from the routine childhood vaccine schedule in the US (complete by the end of 2002) there has been no change in the rate of increase of autism. Advocates of the thimerosal-autism hypothesis predicted that autism incidence would plummet. It didn’t.

He goes on to make what Orac frequently calls “the toxin gambit” by listing listing the “scary toxins” found in many vaccines. But the issue is the same – what’s the dose, and what is the evidence for safety?   For example, he mentions formaldehyde without mentioning the fact that the amount found in vaccines is less than the amount formed naturally in the body as a consequence of normal metabolism.

He writes: “Triton X-100: A detergent that should not be injected into the human bloodstream.” Well – vaccines are not injected into the bloodstream. They are given either intramuscularly or subcutaneously – never intravenously. That aside, again we are left with the real question – is it safe at the doses given? This, of course, has been studied and Triton X-100 has been found to be safe in those flu vaccines in which it is used.

Gucciardi then takes a swipe at another anti-vaccine claim – that the young immune system cannot handle the stress of vaccines and this can lead to, among other things, autoimmune disease. He gives a single reference to this – an article by one crank (in my opinion), Russel Blaylock, posted on the website of another crank, Mercola. Again we see that Gucciardi relies exclusively on secondary anti-vaccine sources (violating basic rules of journalism and scholarship).

The information he is citing has to do with the HepB vaccine, not the flu vaccine (and so is of dubious significance to the issue at hand, unless your goal is to fear-monger about vaccines in general). He writes:

In essence, they found that the babies responded to the vaccine by having an intense Th2 response that persisted long after it should have disappeared, a completely abnormal response.

This is a complex topic and I cannot do it justice in this post. But quickly – this issue has been and is being researched. One thing we have learned about the immune system is that it is damn complex, and we cannot extrapolate from simple basic science findings to net clinical outcomes. So citing one paper about differences in immune response between children and adults is not enough to make any conclusions. Further, his characterization of the response of children in this study as “a completely abnormal response” is nonsensical and not based on any science.

The massive cherry picking that Gucciardi is engaged in is also evident. Other studies, for example show that children who received the HepB vaccine had no increase in autoantibodies years later. There is, in short, no evidence that giving young children vaccines signifciantly increases their risk of developing autoimmune diseases. Rare cases of vaccine-induced autoimmunity are possible and reported, but you can also get autoimmunity from getting the diseases that the vaccines prevent.

As with everything in medicine, you need to take a risk vs benefit approach. Vaccines have risks, but they are generally low, while the benefits are large and clear.

Conclusion

At every step Gucciardi mindlessly repeats long-discredited anti-vaccine canards, cites anti-vaccine sources as authoritative, cherry picks evidence, and grossly misrepresents the facts.

The EPA limit for mercury claims is especially egregious, and so easily and demonstrably false.

But, flu season is on the way, and now is the time to get  your flu vaccine if you want to be protected. It is therefore also the time for the anti-vaccine movement to trot out their tired arguments, doing their best to hamper effective public health interventions with fear-mongering.

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58 responses so far

58 Responses to “Fear Mongering the Flu Vaccine”

  1. Dawnon 21 Oct 2011 at 8:56 am

    I got my thimerosal dose on Tuesday. Funny thing, except for some muscle aches, headache, and mildly sore arm, I had no reaction. No autism, no dementia, nothing. I feel cheated! (OTOH, if I don’t get the flu, I will be delighted.)

    I even managed to get 2 other people in my office to get their shots the same day. Both had forgotten to sign up, but both readily went up (they have young children) and got their shots.

    May see if I can go comment on the article you linked too, Steve.

    (p.s. I have recommended several of your postings to physicians I work with, especially the MS postings. They find them very helpful and informative. So Thanks!)

  2. Dawnon 21 Oct 2011 at 9:06 am

    (My comment, in case it doesn’t get posted on The Canadian:)

    Gee. A journalist who doesn’t research his subject before writing scaremongering. Color me surprised that he’s posting nonsense about the flu vaccine.

    Just to clarify: IF your flu shot has thimerosal in it, it contains ethylmercury. The EPA limits are for METHYLmercury – you know, the kind you are exposed to by eating tuna fish. Ethylmercury is processed and out of the body about 3 times faster than methylmercury and does not accumulate in the body.

    AND, most flu shots don’t even contain thimerosal (ethylmercury). Single dose injections don’t, because there is no risk of bacterial contamination. Only if you get your injection drawn up from a multi-dose vial will you be given a flu shot with thimerosal.

    So, Mr Gucciardi, please, next time you play investigative reporter, will you keep to the full facts instead of making them up?

    Thank you.

  3. Dawnon 21 Oct 2011 at 9:10 am

    Funny, I created an account, but STILL couldn’t get my comment to post, after trying multiple times. Why, it’s like Mr Gucciardi has disabled commenting on his post. It was written October 19th and has NO comments on it. How very strange….

  4. Cow_Cookieon 21 Oct 2011 at 10:00 am

    I’m not an anti-vaxer. I think all products should be held to the same standard (ie. no special exception for supplements, homeopathy and the like). I’m an atheist and demand evidence for people’s claims — happily rejecting those claims when evidence is lacking.

    But I’ve never quite understood why the flu vaccine, in particular, is so important. Doesn’t a flu vaccine increase the likelihood of mutation that could lead to even worse strains of the disease? I fully understand the need for other vaccines. Polio, measles, menigitis, etc. are all life-changing and potentially fatal diseases. So, as Dr. Novella said, the risks outweigh the benefits. But the existing strains of flu are really just an annoyance for most of the population. Wouldn’t flu vaccines create natural selection pressures that could give deadly strains like those at the turn of the 20th Century an evolutionary advantage over the less serious strains we deal with now? In other words, why don’t the risks-benefits shift?

    I suspect the answer lies in herd immunity. I may only miss a few days of work when I get the flu, but I could pass it on to an infant, senior citizen or other vulnerable person for whom the consequences would be direr. So I still get my flu shot regularly. At any rate, I’m sure someone here has some details I’m missing.

  5. Steven Novellaon 21 Oct 2011 at 10:22 am

    The flu is not just an annoyance. It causes hundreds of thousands of hospitalizations in the US alone each year, and 20-30 thousand deaths.

    The vaccine does not encourage evolution of more deadly strains. It reduces it. When bugs reproduce and spread around, that increases evolution of new strains. Reducing spread and infections reduces the emergence of new strains.

  6. Webbstreon 21 Oct 2011 at 10:26 am

    @Cow_Cookie: It’s not like the (poor) argument where washing your hands is bad because it leads to soap-resistant germs developing, the flu mutates each year no matter what you do, short of immunizing everyone possible on the planet for a few years. This is because flu vaccines change every year, while something like soap or antibiotics stays pretty much the same over a longer period of time, until it stops being effective.

    Looking back, I’m not sure I wrote that in the most comprehensible way. Yes, it has to do with herd immunity. The more people get immunized each year the better the odds are we could someday even exterminate something like influenza (short of it jumping between animal species). And yes, the more people who get immunized the better the odds someone who it could be fatal for won’t get the disease.

    I should sleep, I am almost certain I’m not making sense here.

  7. Cow_Cookieon 21 Oct 2011 at 10:35 am

    No, both you and Dr. Novella were very clear. Thank you.

  8. LivingWithMormonson 21 Oct 2011 at 3:25 pm

    Got my (free!!!!) shot this week at work.

    I’d just like to add that I love you skeptics out there. People like cow_cookie who are willing to change or “improve” their ideas about a topic based on evidence. I wish we weren’t the minority :(

  9. Steven Novellaon 21 Oct 2011 at 3:35 pm

    I got my flu shot today as well.

  10. tmac57on 21 Oct 2011 at 3:55 pm

    @Webbstre- I know that anti-biotic soaps are implicated in creating resistant strains of bacteria,but I have never heard anything about plain soap causing a problem.In fact that it what pretty much every source that I have read has recommended:Frequent hand washing with plain soap and water,to avoid spreading disease.

  11. Karl Withakayon 21 Oct 2011 at 3:55 pm

    I got the shot a couple of weeks ago, which was a couple of weeks after a mild case of the flu. #Badtiming

    Here’s an anecdote for what it’s worth:

    Prior to last year, I never got a flu shot (out of laziness) but since they started offering them at work, I now get them every year. I still get the flu each year, but it has been much milder the past two years since getting the shots. The flu used to make me miss a week+ of work every year (and sometimes twice a year on each end of the flu season), but only 3 days last year and 2 this year.

    As an interesting side note, this year’s flu vaccine is for the exact same strains as last year. I understand from the CDC that people should still get the shot, even if they got last year’s, as it does provide a booster effect and increased protection against those strains.

  12. tmac57on 21 Oct 2011 at 4:03 pm

    Karl-They told me that it also covers the H1N1 strain as well as the seasonal flu when I got mine.

  13. son 21 Oct 2011 at 4:17 pm

    I will happily believe in flu vaccine efficacy when strict reviews of vaccine study methodological quality do not come to the conclusions cited below. And I will be more likely to believe pro-vaxers that do not get a hissy fit when their preconceived notions are scientifically disproved.

    “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 studie*s. The content and conclusions of this review should be interpreted in light of this finding.”

    Vaccines for preventing influenza in healthy adults. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD001269.

  14. Steven Novellaon 21 Oct 2011 at 4:26 pm

    S

    Mark Crislips review of the evidence is more thorough and informative, in my opinion: http://www.sciencebasedmedicine.org/index.php/flu-vaccine-efficacy/

    He writea: “You can conclude that neither the vaccine nor the data is perfect, and decide the vaccine is not useful.

    Or you can look at the preponderance of data, with all the flaws, nuance, subtleties and qualifiers, and conclude the flu vaccine is of benefit. The vaccine decreases the probability of morbidity and mortality. It is a good thing.”

  15. Karl Withakayon 21 Oct 2011 at 5:20 pm

    @tmac57

    Last year’s shot also included the pandemic H1N1 that was introduced by itself the previous year (2009). It is the strain of H1N1 used for this and last years seasonal flu vaccine.

    FROM CDC:
    “WHO recommended that the Northern Hemisphere’s 2011–2012 seasonal influenza vaccine contain the following three vaccine viruses:

    * an A/California/7/2009 (H1N1)-like virus;
    * an A/Perth/16/2009 (H3N2)-like virus; and
    * a B/Brisbane/60/2008-like virus.

    These are the same viruses that were selected for the Northern Hemisphere for the 2010-2011 influenza vaccine. ”

    A/California/7/2009 (H1N1) is the 2009 pandemic strain, sometimes called the 2009 Swine Flu or Mexican Flu.

    Interestingly, both the Northern and Southern hemisphere vaccines are for the same strains for 2011, which often isn’t the case.

  16. daedalus2uon 21 Oct 2011 at 6:44 pm

    The Cochrane review on flu is really caught up in methodolatry. They only look at double blind placebo controlled trials which makes the data set they then look at very thin.

    The Cochrane reviews on Oscillococcinum

    http://www.ncbi.nlm.nih.gov/pubmed/19588329

    Is highly flawed, and is also withdrawn, but since it is essentially the same as the previous few Cochrane reviews on Oscillococcinum (there has been no new work published on oscillococcinum in the last decade). Earlier Cochrane reviews found oscillococcinum to be effective at reducing the length of flu illness by an average of 0.28 days (based on the same studies).

    There is pretty good evidence for health benefits from flu vaccination for groups that are more at risk than healthy adults (the lowest risk group). The lowest risk group would require the largest clinical trials to show a benefit (because the benefit is likely to be small because they are a low risk group) which would be the most expensive trials to do.

    You can’t do double blind placebo controlled trials for flu in the elderly because it is unethical. Very large non-placebo controlled retrospective studies (HMO studies with hundreds of thousands of subjects) have shown pretty good effects for flu vaccination in the elderly.

    http://www.ncbi.nlm.nih.gov/pubmed/21818350

    The studies are not perfect, but no study ever is. Every comparison of one treatment population with another is problematic because no population is identical and exactly equivalent to the n=1 patient being considered for vaccination.

  17. nybgruson 21 Oct 2011 at 9:41 pm

    The flu season here in Oz is winding down and I managed to make it through the entire year without getting sick (and actually didn’t get the shot either, out of pure laziness).

    However, I will be back home stateside in just 3 weeks (eek! that means exams are just around the corner….) and I will be getting my flu shot ASAP when I do. Mostly because I can just go back to my old hospital of employment and sweet talk the house supervisor or the surgical director to hooking me up :-)

    and in regards to s’ comment: there is also no RCT data that airbags actually save lives and there are many cases of airbags causing harm – even more harm than they otherwise might have prevented. But I still like having airbags in my car.

  18. nybgruson 21 Oct 2011 at 9:42 pm

    I should clarify – no RCT data on actual people. I suppose the crash test dummy trials sort of count, but I think the commentariat here gets my point. :-)

  19. Blair Ton 21 Oct 2011 at 11:11 pm

    As a Canadian, I have never heard of this “publication”, and I wonder if you are giving the author too much credit as a “journalist”. I browsed their articles, and found that it is a weird mix, including many articles on extraterrestrial aliens controlling our planet. This is not a main stream news source. However – good job in taking apart the vaccine claims.

  20. ChrisHon 21 Oct 2011 at 11:31 pm

    I and two my children went in today to get flu shots. We all seem to be fine.

    Now my next trick is to nag dear spouse to get his at work, and son in college who is not living at home to get his at the student health clinic.

  21. thequiet1on 22 Oct 2011 at 1:34 am

    I had a look around that ‘news’ site and, as Blair T says, it’s koo koo bananas.

    Just a couple of examples:

    “Michael Cremo talks about his investigations into the ancient origins of humankind and how the Darwinian theory of evolution has been sponsored by the scientific community against all the evidence to the contrary.”

    And this sober reporting of “Extraterrestrial War in the 1930’s linked to Historical Accounts.”

    “The result, in part, is that human memory of such a war was “erased” from our “official time”. Our current time line therefore reflects the alteration which took place. Ethical Extraterrestrials operating on a higher-dimensional consciousness would be able to witness such an alternation, and then report to human contactees like Alex Collier, about the nature of such time-space alternations.”

    It’s good to see vaccine denial has found it’s rightful home.

  22. Steven Novellaon 22 Oct 2011 at 7:04 am

    I suspected the paper was a rag. But this guy presents himself as a journalist. Also, the 250 times the EPA dose claim is very common. You will find it repeated over and over again on the intertubes.

  23. son 22 Oct 2011 at 7:06 am

    Dear Dr Novella, thank you for pointing out Crislip’s article to me. It was certainly both long and interesting for many reasons, but his long argument does still not prove or disprove anything. It can be divided in slippery rhetoric (see below), stating the obvious truism that science is often work in progress and that todays scientific truths may just as well be tomorrows falsehoods and a list of cherry picked articles from PubMed. He does also avoid Jefferson’s very important point re study quality and funding source and the factum Jefferson’s group base it’s analysis on a strict statistical and methodological analysis of a very large amount of studies. Yes Daedalus, sure it could be called “methodolatry” if you wish a debate based on ad hominem slurs, but I do prefer “methodolatry” until strong good evidence is available.

    (BTW The oscillococcinum review authors did state that “Current evidence does not support a preventative effect of Oscillococcinum-like homeopathic medicines in influenza and influenza-like syndromes”. Yes the study may be stupid and flawed because it used flawed sources as input. GIGO is always a problem when you analyze other studies and hopefully skepticism and peer review sooner or later catches that. So, what do you want to say, except trying to malign Cochrane with association by guilt, because you found one withdrawn GIGO study?)

    So, anyhow, what’s my problem with Crislip’s argument. Well, he begins by assuming that the (only?) cause low vaccine efficacy is because ofn choosing the wrong strain, while ignoring that it could just as well be because the vaccine does not have an effect per se. His second point is akin to the psychic unbeliever argument, where the unbelievers have been replaced by “immunoincompetent” elderly. His assertion is, if I may be sarcastic, that flu vaccine studies show no effect because the target group has, uhm, no immune reaction, and no effect in the healthy group because they, gee, are healthy. Thirdly he advocates the herd immunity argument that flu vaccines may show no effect because not enough people are vaccinated and then promptly appeals to fear (“vulnerable people”).

    The he proceeds with an ad hominem attack combined with poisoning the well and straw man: “anti vaccine goofs who seem to require that vaccines either be perfect, with 100% efficacy and 100% safe, or they are not worth taking”.

    After which he uses argument me made against the “goofs” to support his position and make yet another appeal to fear: “The influenza vaccine is not 100% efficacious in preventing disease, but it is as close to 100% safe, and much safer than the disease”.

    And I could go on with this for along long time. But I’ll spare you that.

    In the end Crislip’s argument amount, in my opinion, to an unconvincing expose of wishful thinking about flu vaccine effectiveness. And that is certainly what policy or decisions should not be based upon.

    On a personal note it may be worth to point out that I am vaccinated for about everything (childhood disease, pneumonia, “travel diseases”). But I have never seen any logical reason to vaccinate against the flu. The swine flu scaremongering craze also made me read a lot on PubMed and also to compare the socio-economically similar Sweden*, Australia and New Zealand.

    A major aside begins here – - – - – - – - – - – - -
    There was essentially no difference in duration, peak and mortality** for the white population, although New Zealand had less confirmed cases/100000 and vaccinated Sweden more cases in the 0-50 years group. The Swedish vaccination program showed absolutely no effect on the number of confirmed cases. But Sweden (and Finland) saw an astonishing increase in children of narcolepsy with cataplexy (currently suspected to be related to the AS03, squalene adjuvant—do also notice that most, >90%, had not been infected with swine flu***), while Australia and NZ saw a markedly higher mortality in aboriginal peoples.

    And after having done that I am very very much more skeptical against sweeping and scientifically unsubstantiated claims of effectiveness. I must also say that I was pretty horrified but the very common discrepancy between study results and claims made in especially the abstract of many of the studies I read, and also but the oftentimes sloppy data analysis. Today I am always a priori skeptical of medical claims. Especially when there are vested interests that could make billions of dollars if their claims are turned into treatment policy. It is sad as I had earlier naively assumed that medical research was based on sound scientific principles and skepticism.

    Some notes – - – - – -
    *In Sweden the flu propaganda was grotesque: “deserted schools…shops”, “humanity is threatened”, implicating that those that do not vaccinate are “murderers”. (Viruset och vaccinet, JMG report nr 63, Univeristy of Gotheburg). A few doctors were even prohibited to make statements to the media, and threatened to be fired by their employers. As the science journalist Inger Atterstam of Svenska Dagbladet (major conservative Swedish newspaper) put it: “The campaign [for mass vaccination] has in fact been so tough and ideological that no one has been allowed to question the official [government and pharma and swedish CDC] line. Doing so was regarded not only as irresponsible but also as malicious and disloyal. [Pro-vaccine] forces effectively rallied and critical voices silenced. A sensible discussion was almost impossible to make.”

    **It may be of interest to point out that childhood (0-7 years) mortality was approximately 1250/100000 in the 1750ies in Sweden, then progressively diminished to about 20 in 1971 when the Swedish childhood vaccination program began. So childhood vaccination had minimal effect on mortality compared with historical figures. Mortality decreased drastically beginning with clean water and improved food production. (Variola had diminished drastically before vaccination began.)

    ***Despite the fact that >90% of the affected children had not been infected by the swine flu, the Finnish authorities then proceed, in the same press statement, to praise the vaccine for reducing mortality and IC. Hmm… (http://www.thl.fi/en_US/web/en/pressrelease?id=26352)

  24. son 22 Oct 2011 at 7:07 am

    oops apologies for the massive bold-facing, Dr Novella could you, if possible, please add the / to the ending tag

  25. BillyJoe7on 22 Oct 2011 at 7:32 am

    s,

    “I have never seen any logical reason to vaccinate against the flu. The swine flu scaremongering craze also made me read a lot on PubMed”

    You may be interested in the following comment by Mark Crislip at SBM:

    http://www.sciencebasedmedicine.org/index.php/alternative-vaccination-schedules/

    “Having spent most of my adult life thinking about infections and their treatment and prevention, I find the field almost impossibly difficult. The decisions that go into the CDC vaccination schedule represent the best opinion of some the brightest and most experienced minds in medicine… I would only question the CDC if I had spent three professional lifetimes in the field of vaccinations. And yet time with the googles and talking with friends and family is evidently enough to come up with your own approach to the vaccination schedule. I am glad these [people] are not also responsible for deciding on doing an appendectomy or piloting my airplane. I have asked this in the past, but what is it about medicine where people think they can know better with no experience and little education? It is my field of expertise and I am more often in not uncertain if I know better.”

  26. ccbowerson 22 Oct 2011 at 8:25 am

    BJ- the quote you used is spot on for people like “s.” Its a good thing to be a skeptic, and educate yourself, which may involve personally investigating evidence and claims. Its another thing to think that you can educate yourself sufficiently to make better judgements than the consensus in a legitimate field… with people that have expertise and spend their entire professional lives on a given subject. This is not the same as an argument from authority, it is intellectual humility on behalf of the individual, or respect for expertise. Of course experts can be wrong, but you’d better have a good reason for disagreeing, well beyond “I disagree” or conspiracy talk.

  27. nybgruson 22 Oct 2011 at 8:57 am

    sure it could be called “methodolatry” if you wish a debate based on ad hominem slurs

    That’s not an ad hominem.

    Yes the study may be stupid and flawed because it used flawed sources as input.

    It’s stupid because homeopathy is stupid. The point daedalus was trying to make is that when you try and review something based on RCTs when the very premise of what you are reviewing is stupid, false, or incomplete and draw conclusion based solely on that you will always have a bad review. And that is an example of methodolatry – the valuing of RCTs so highly as to ignore everything else, regardless of how well it may inform the opinion.

    while ignoring that it could just as well be because the vaccine does not have an effect per se.

    And I don’t think I need to go any further than this. You say you are vaccinated against all sorts of stuff, but that somehow, for some unknown reason the basic science of specifically the flu vaccine is called into question? You think that is a valid rational for argument against Crislip’s point? That is an epic fail on your part.

    in my opinion, to an unconvincing expose of wishful thinking about flu vaccine effectiveness

    BJ’s comment fits here perfectly.

    The he proceeds with an ad hominem attack combined with poisoning the well and straw man: “anti vaccine goofs who seem to require that vaccines either be perfect, with 100% efficacy and 100% safe, or they are not worth taking”.

    It is great to know the names of the logical fallacies. Next step: learning to use and apply them correctly.

  28. son 22 Oct 2011 at 9:41 am

    @BillyJoe7, thank you for your reference to the Crislip article. But may I point out that my gripe is with the scientific evidence concerning *flu vaccines*. Not the science behind vaccinations that stimulate sterilizing immunity, nor with pneumococcal vaccines.

    Crislip’s comment is a bordeline non-sequitur though. I am equally glad as Crislip that these people do an excellent job. The evidence showing that airline pilots normally are the best choice to “drive” an airliner is overwhelming, but also the evidence that a total novice can be instructed on the spot to at least land.

    Same goes for appendectomies. But diagnoses also have an about 20% false negative rate (Graff et al). And yes I am glad they make the decisions for me, but I sure as hell am glad that I am skeptical enough to maybe require an additional opinion, be it by reading PubMed or relevant literature or getting an imaging study or contacting another medic. Would you trust a diagnosis that has on average a 20% false negative rate just because it is based on what the experts say?

    The virology etc. experts are of course also normally best choice to make a recommendation based on their knowledge, but it does not mean that an absolute religious trust should be placed in them. Medicine is not maths! And when reality conflicts with expert advice, alternative hypotheses should be pursued. And contrary opinion listened to. Especially if coming from a reputable source like Cochrane. Sort of expert vs expert.

    @ccbowers, why do you not read what I write before expressing a hearsay opinion? Q to you do you believe the expert opinion on global warming or not? If not please do explain why virology experts are to be trusted but not climatology experts?

  29. son 22 Oct 2011 at 9:55 am

    @nybgrus
    <That’s not an ad hominem.
    Why not it is a classical pejorative used to denigrate the unbelievers. I.e those who do not believe in God. Thus a methodolatric person per extension is one who do not follow dogma. That is why I prefer to be methodolatric than folloow dogma.

    <The point daedalus was trying to make … or incomplete and draw conclusion based .
    Yes GIGO (garbage in–garbage out) as I said. We are in complete agreement. I do not understand why you believe we are not

    It’s stupid because homeopathy is stupid. The point daedalus was trying to make is that when you try and review something based on RCTs when the very premise of what you are reviewing is stupid, false, or incomplete and draw conclusion based solely on that you will always have a bad review. And that is an example of methodolatry – the valuing of RCTs so highly as to ignore everything else, regardless of how well it may inform the opinion.

    <You think that is a valid rational for argument against Crislip’s point? …epic fail on your part.
    That was a weird argument. I specifically point to the evidence put forth by Tom Jeffersons reviews and my own research (the latter be it as it may be).

    <BJ’s comment fits here perfectly.
    See my reply to BJ

    <It is great to … learning to use and apply them correctly.
    Please do enlighten me then…

  30. son 22 Oct 2011 at 9:59 am

    Grr, edit of previous comment. The “It’s stupid because homeopathy … the opinion.” was supposed to be deleted.

  31. ccbowerson 22 Oct 2011 at 11:12 am

    “Q to you do you believe the expert opinion on global warming or not?”

    Short answer is yes, but I’m not interested in side tracking to a climate change discussion. Both topics are complex and dissimilar in enough ways to cloud the discussion here. Certainly there are levels to evidence and expert opinion based upon weaker data is subject to more scrutiny for individuals than for those topics for which there is ample evidence. You are putting flu vaccination into the category I just mentioned, I assume.

    I would like to know if you think there is legitimate scientific controversy within medicine (or related field) regarding the public policy recommendation for people to get the flu vaccine due to efficacy concerns? Note, I am referring to whether people should get the vaccine based upon efficacy. If so, provide references. If not, are you just making an exception for yourself?

  32. ccbowerson 22 Oct 2011 at 11:19 am

    Getting the flu is a great reminder to those who blow the vaccine off. I’ve had 2 family members recently who were reminded of how terrible the illness feels even for otherwise healthy people. If that is not enough, the thought of contributing to another person’s illness or death (e.g. grandparent), just because that individual is unlikely to be seriously ill from the flu seems to be a moral problem. Hopefully progress on a more effective universal flu vaccine with will make all of these discussions moot, but I still view this as a non-controversy

  33. daedalus2uon 22 Oct 2011 at 11:53 am

    The Cochrane review of oscillococcinum is flawed because the Cochrane review process is flawed. That is not the fault of oscillococcinum or homeopathy, it is the fault of the Cochrane reviewers for using a flawed review process.

    The Cochrane process is flawed in multiple ways. According to Cochrane, all RTCs (even of homeopathy) are valuable and can be used to determine efficacy and all data from non-RTCs is of zero value. Putting blinders on and only looking at part of the data can’t give as good or reliable an answer as looking at all of the data.

    Being snobbish about data is narcissism and an example of Cargo Cult Science. The Cochrane reviewers sit in their ivory towers and sneer at all non-RTC sources of data. It makes their job easier because they have less data to review. If there were large RTCs, it wouldn’t take an expert to review it, you could write a script to do so. You could write a script to do what the Cochrane reviewers do, if there are no large RTC s, default to saying there is not enough data, review over.

    If the goal of the Cochrane reviewers is to provide guidance to patients and clinicians as to what treatments are likely to be beneficial, they fail at that goal when they throw up their hands and say “not enough big RTCs”. If their goal is to sit in their ivory tower and sneer at clinicians and patients who must make clinical treatment decisions based on what data is available, they succeed.

    In doing my analysis of multiple Cochrane reviews, I find the Cochrane review process to be unreliable because it finds things like homeopathy to have efficacy. If the Cochrane review process is so unreliable that it can’t identify something like homeopathy, then the Cochrane review process is useless and not worth considering.

    Cochrane does say that flu vaccine is effective in some populations. If it is effective in some populations, what is there about another population that would suddenly make flu vaccine not effective? Cochrane provides no insight as to why efficacy in some populations would not translate into efficacy in others, other than because large RCTs have not been done. This is pure methodolatry.

    What about my demographic? Male, sedentary, single, skeptic, researcher in nitric oxide physiology? Oh no, there has not been a large RTC trial of flu vaccination in my demographic, no one can predict if flu vaccination would help me or hurt me.

  34. son 22 Oct 2011 at 12:27 pm

    @daedalus
    Quick reply: Then I suggest you get employed (you definitively have the qualifications) by the Cochrane Collaboration and help them make better reviews instead of making sweeping claims that their use of RTC is ivory tower nonsense. Or publish a critique in some relevant journal. E.g. BMJ or PLOS. I would avidly read that.

  35. son 22 Oct 2011 at 12:30 pm

    PS My demographic? Male, sedentary, with family and children in school, skeptic, software engineer? And there has not been a large RTC trial of flu vaccination in my demographic either, but no one in my family ever gets the flu or ILI.

  36. ccbowerson 22 Oct 2011 at 1:28 pm

    “but no one in my family ever gets the flu or ILI.”

    Do you think this is a meaningful statement? Anectdotal evidence worthy of an informercial, and it says nothing about the likelihood of becoming ill.

  37. BillyJoe7on 22 Oct 2011 at 3:06 pm

    s,

    “a total novice can be instructed on the spot to at least land.”

    If there is no pilot available, I would be happy for a novice land the plane under the guidance of a pilot. This is a bit different from trusting a novice’s advice on the flu vaccine against the advice of a panel of vaccine experts.

    “Would you trust a diagnosis that has on average a 20% false negative rate just because it is based on what the experts say?”

    Yes – if the alternative is a novice who doesn’t have a clue whether I have appendicitis, gastro, or even a twisted testicle.

    “when reality conflicts with expert advice….”

    I would rather trust the reality as determined by a panel of experts in the field than the reality as determined by a novice googling the internet.

    “Especially if coming from a reputable source like Cochrane. Sort of expert vs expert.”

    There are some excellent articles on SBM that explain where Cochrane fails. Essentially, prior probability is ignored, and the RCT is god. This leads to nonsense such as “further clincal trials are needed for [homoeopathic remedy]” and “true and sham acupuncture work equally well”.

  38. ccbowerson 22 Oct 2011 at 5:26 pm

    “…true and sham acupuncture work equally well.”

    Well that is a true statment of equality.

  39. ccbowerson 22 Oct 2011 at 5:30 pm

    …if being misleading is the goal. With a view that double blind randomized controlled trials are the only valid form of evidence, you would think that they would understand the purpose of the control. Apparently not.

  40. daedalus2uon 22 Oct 2011 at 5:42 pm

    Hindsight is usually 20-20.

    My ex was misdiagnosed with appendicitis because it didn’t hurt enough. Even after it ruptured it didn’t hurt enough. But as she said, after the secondary abscesses started to rupture, then it started to hurt. But then she needed a month in a hospital to recover, and has a 6 inch scar where the drainage tube had to be.

    That is what you get when you try to reduce false positives too low, you start to miss true positives with false negatives. In the case of appendicitis, a false negative is a lot worse than a false positive. One side effect of catching all of the true positives is that then you have some false positives.

  41. SimonWon 22 Oct 2011 at 5:56 pm

    A friend mentioned the superbug argument against widespread influenza vaccination, when I mentioned it on my rather silly blog post last year, so perhaps it needs a fuller taking down than I gave it then?

    http://waters.me/politically-unworkable-ideas/vaccinate-the-rich/

    Got my influenza vaccine a couple of weeks back, but am losing the will to discuss the issue gracefully with those who are simply ignorant, or stupid.

    The last study I saw noted that elderly people with influenza spent less time in hospital for all conditions, and that this reduction alone more than covered the cost of vaccination. Of course this would not have met the Cochrane criteria since it wasn’t an RCT, or case controlled study, but merely looked at length and cost of medical treatment in those vaccinated and not vaccinated. Perhaps not the optimum study design, but on the other hand it was a practical study commissioned by practical people who simply wanted to know if it was cheaper to vaccinate or pick up the bills for not vaccinating. The design answered the question raised, which was not even if it prevents influenza (it did), or how it works, but simply if the intervention is cost effective.

  42. locutusbrgon 22 Oct 2011 at 7:33 pm

    S
    The influenza vaccine is not 100% efficacious in preventing disease, but it is as close to 100% safe, and much safer than the disease”.
    And I could go on with this for along long time. But I’ll spare you that.

    Please indulge me and go on for long time I find your writing style interesting and your thought process fascinating.

    I would love to hear your argument related to this statement.

  43. BillyJoe7on 23 Oct 2011 at 5:14 am

    daedalus,

    I think your ex may have had a retrocaecal or pelvic appendix.

    http://en.wikipedia.org/wiki/Appendicitis

    In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch.

    “That is what you get when you try to reduce false positives too low, you start to miss true positives with false negatives. ”

    Yes, but are you claiming to know better than the experts where the balance point lies? ;)
    (I take it you don’t want to subject everyone with a bellyache to a surgical procedure)

  44. ccbowerson 23 Oct 2011 at 9:04 am

    “Yes, but are you claiming to know better than the experts where the balance point lies?”

    Not referring to Daedalus’s specific case, I think that it is important to distinguish between an individual “expert” assessment of a specific situation, and the expert consensus on a scientific issue. The latter is much more reliable than the former, and I recommend a higher level of skepticism (but reasonable) of the former.

  45. daedalus2uon 23 Oct 2011 at 11:44 am

    Billy Joe, I was not trying to substitute my non-expertise for the expertise of real experts. I simply raised an anecdote to illustrate that you can’t look at only one type of error to tell if your diagnostic process is good enough. You can have zero false positives by never taking out an appendix. You can have zero false negatives by taking out every single one.

    I raised the point to counter the facile (and wrong) analysis by s, that simply because there are false negatives in appendicitis, that the “experts” are often wrong and patients should second guess the “experts” by spending a few hours on google.

    It is not possible to acquire medical expertise in a few hours, not from google, not from anywhere. It takes 10,000 hours to become an expert. If you haven’t put in that kind of time, your opinion is not worth as much as the opinion of an expert who has.

    My understanding is that in the case of appendicitis, the cases that are misdiagnosed are not distinguishable. That is patients with identical symptoms can be positive or negative for appendicitis.

    What you can do is evaluate the process by which the expert comes to their opinion. Do they look at facts? Do they analyze them with logic? Can they explain the reasoning behind their diagnosis? Do they know what the standard of care for this particular condition is? Do they subscribe to crank beliefs? If you ask about vaccines, chelation, reiki, homeopathy, acupuncture, what do they say?

    I disagree with CC, there isn’t a “scientific consensus” on whether a particular patient has appendicitis given a constellation of symptoms. There may be a “standard of care” where a certain constellation of symptoms suggests a certain course of treatment which may result in removal of a certain percentage of non-inflamed appendices. The goal of a differential medical diagnosis is always differential medical treatment, not a “scientific answer”.

    If you want a “scientific answer”, what you want is a research project on an n=1 population, and you should go to a researcher. If you want medical treatment then you should go to an MD, where the best you can expect is “standard of care”. The “standard of care” includes a fraction of false positives and false negatives and is a moving target. If you want something different than “standard of care”, you shouldn’t go to an MD. If you want a promise of a complete cure, go to a quack, they will be happy to promise you that their quack treatment will cure you of whatever you have, until you run out of money.

  46. tmac57on 23 Oct 2011 at 12:02 pm

    It takes 10,000 hours to become an expert. If you haven’t put in that kind of time, your opinion is not worth as much as the opinion of an expert who has.

    Doing 10,000 hours worth of research with motivated reasoning and confirmation bias as your copilot,can end up with you getting a ‘degree in baloney’ though.I have run across crackpots who have an encyclopedic grasp of some of the most ridiculous nonsense that you could imagine.Their opinion is still pretty worthless.

  47. son 23 Oct 2011 at 3:15 pm

    This site is interesting. Even more interesting is the knee-jerk response as soon as anyone expresses doubt about the flu vaccine (or vaccines in general). It is like throwing a grenade in a closed room. The conflagration is massive and very sectarian. My impression is that there seems to be a conflation of many items here.

    1) The acrimonious debate mainly raging in the US about autism and vaccines.

    2) The question whether vaccines against diseases causing sterilising immunity work or not. Consensus is that the vaccines work, but the anti-vaxers disagree here.

    3) The question if vaccine adjuvants can cause disease. Consensus seem to be that, yes there is a very minimal risk, but anti-vaxxers say it is major–especially if mercury is used. (The Pandremix narcolepsy scandal in Sweden and Finland is nevertheless a lesson that even small risks can ruin the life of the few affected.)

    4) The question if vaccines cause disease (other than the intended reaction). I assume there is consensus that they do if there are know contaminants or production errors other. If I understand this correctly anti-vaxxers believe that this may be the cause.

    5) the question if the vaccination program in the US is to severe. (For an interesting comparison with other countries see “Infant mortality rates regressed against number of vaccine doses routinely given” in Hum Exp Toxicol 2011.)

    6) The fact that vaccines had minimal import on diminishing mortality is often confused with the fact that vaccines diminished morbidity and with anti-vaccine sentiment. (E.g. childhood mortality in Sweden went from on average 1250/100000 children 0-7 years of age in the 18th century to 20 in 1970, when the national childhood vaccination program began. 45 if pertussis vaccination is counted. Oddly enough variola vaccination had had no discernible effect on the total mortality figures for the 0-7 group. The huge drop is due to improved hygiene, clean water and agriculture.)

    6) The question if flu vaccines have any meaningful effect. The hypothesis I doubt.

    When I doubt flu vaccine effectiveness I get lambasted for in some way implicitly also support 1-4 above and being an idiot (the latter of course put in other and more words, but never the less meaning that).

    If I point to the Cochrane Collaboration they to are called idiots too. And the evidence based method they use (the analysis of RCT’s) is immediately called into question. Not because of inherent problems in the methodology, but more or less thrown out altogether as flawed. If so a lot of science is invalidated…

    Then I am beat on the head with authority. I shall believe authority (preferably 10000 hours worth of research ;-) . (Hmm were do we put Michael Behe? Both nutter and expert?) As I said before GIGO (“garbage in garbage out” for the acronym challenged).

    And finally a bunch of people sport their flu shots as some religious moral vanity badges.

    My impression of this debate is that it sectarian, not evidence based.

    Sad it is.

    And btw I am trying to find a logical and consistent refutal of the Cochrane paper that is not lofty expert authority, but that systematically analyses the points made in the Cochrane paper and then puts forth better evidence. No success yet (but may search terms may not be optimal).

  48. BillyJoe7on 23 Oct 2011 at 4:29 pm

    daedalus,

    Sorry for the misunderstanding. You are obviously on top of this.
    (And thanks for the informative reply).

  49. BillyJoe7on 23 Oct 2011 at 4:41 pm

    s,

    Instead of wasting a large post simply stating what everyone is saying in this commentary, why don’t you just respond to the criticisms. For example, we have indicated why Cochrane is flawed but you don’t seem to be interested in replying to that at all except to state that we are criticising it. Hey, we know that already. Yes, we are criticising it. If you disagree, why do you disagree.

  50. son 23 Oct 2011 at 5:34 pm

    OK no Cochrane then but quotes from the abstract or text of three papers from other authors expressing doubt on effectiveness estimates at least in the elderly. And are additional reasons why I doubt overall purported effectiveness,.

    1) No mortality decrease found despite increased vaccine coverage.
    Recent excess mortality studies were unable to confirm a decline in influenza-related mortality since 1980, even as vaccination coverage increased from 15% to 65%. Paradoxically, whereas those studies attribute about 5% of all winter deaths to influenza, many cohort studies report a 50% reduction in the total risk of death in winter–a benefit ten times greater than the estimated influenza mortality burden. New studies, however, have shown substantial unadjusted selection bias…”
    Lancet 2007: https://www.ncbi.nlm.nih.gov/pubmed/17897608

    2) Never vaccinated survive, but not those previously vaccinated.
    “…Forgoing vaccination predicted death in those who had received vaccinations in the previous 5 years, but it predicted survival in patients who had never before received a vaccination
    J Infect Dis 2010: https://www.ncbi.nlm.nih.gov/pubmed/19995265

    3) Best IVE before vaccination.
    “This study returned to the administrative databases that were among the first to show substantial reduction in serious influenza outcomes among immunized elderly. In revisiting the Manitoba database, we exposed similar evidence for bias that others have found, with the most pronounced but implausible effects (i.e., differences between immunized and non-immunized groups) observed in the elderly prior to influenza circulation or even vaccine distribution…we found that the ultimately non-immunized group had higher hospitalization and mortality rates than the immunized before the period of influenza circulation. Given the impossibility of a true vaccine effect during the fall period prior to vaccine distribution…”
    Plos1 2011: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0022618

  51. ccbowerson 23 Oct 2011 at 5:50 pm

    “I disagree with CC, there isn’t a “scientific consensus” on whether a particular patient has appendicitis given a constellation of symptoms.”

    Actually you don’t disagree because I never said the above. I actually prefaced my comment by saying that I was not talking about your specific situation.

  52. nybgruson 23 Oct 2011 at 8:10 pm

    @s:

    You keep trotting out this sectarian religious tripe…. it doesn’t apply here.

    You seem to claim you do not support the assertions 1-4 in your above post. However, you don’t mention 5-7.

    5) The infant mortality issue has been addressed. I suggest you add that to your list of what you do not support.

    6) The hygiene argument has also been dispeled.

    7) The crux of this discussion.

    If I point to the Cochrane Collaboration they to are called idiots too. And the evidence based method they use (the analysis of RCT’s) is immediately called into question. Not because of inherent problems in the methodology, but more or less thrown out altogether as flawed.

    As BJ pointed out – you don’t seem to understand why we say so. And your response since then doesn’t demonstrate that you do now.

    Now on to your individual references:

    1) “The remaining evidence base is currently insufficient to indicate the magnitude of the mortality benefit, if any, that elderly people derive from the vaccination programme.”

    That is the key here – they are saying there isn’t robust data to demonstrate conclusively the decrease of mortality in the elderly. They cite some errors and biases in previous data. None of us here would disagree with that. In fact, I’d ask you to find one argument here (anywhere on the cite) that claims such specific and robust data exists.

    2) “We conclude that bias is inherent in studies of influenza vaccination and death among elderly patients.”

    Repeats the same as #1.

    3) “The most pronounced IVE estimates were paradoxically observed pre-season, indicating bias tending to over-estimate vaccine protection…Improved methods to achieve valid interpretation of protection in the elderly are needed.”

    Once again, indicates a paucity of data and improved methods needed. And once again specifically for mortality and all cause mortality.

    Conclusion:

    No one here is arguing that flu vaccine is extremely effective. And even Crislip himself has admitted there is problems with the data. What is the actual effect size? We don’t have a good answer for that. Is there a well designed RCT to demonstrate it? Not really. And that is why the Cochrane review is useless – it only looks at that flawed data and bad RCTs and concludes in the negative.

    But there is more to determining utility than just an RCT. And citing bad studies and reviews demonstrating selection bias and paradoxical effects just shows that what we have done so far is inadequate and we can’t answer with a definitive answer as to what the effect size may actually be.

    However, Bradford-Hill criteria still exist and in this case, combined with the extremely good safety profile of flu vaccination, are reasonably sufficient for asserting the utility of flu vaccination. We know the basis for how vaccines work and the flu vaccine follows that same principle. We know that flu is contagious and common. We know that even without perfect antigen matches flu severity is decreased after vaccine. We know that some 30-50 thousand people a year die annualy from the flu and that even in those that don’t die directly from the flu the inflammatory burden imposed on them by contracting the flu can and does increased other causes of mortality. We also know that the vaccine is reasonably cheap, readily administered, and well tolerated. And I have yet to see any study that has robust data demonstrating an increased mortality or morbidity from flu vaccine (or really any vaccine for that matter).

    So all-in-all, the only argument you have is that we don’t have robust data for the exact effect size and that we are possibly over-estimating it. Such data is messy and difficult to obtain and many of the authors here have written on the topic. That is a very reasonable argument and, IMO, a good call to have better data so we can incorporate better metrics. However, it is a far cry from being able to assert that the flu vaccine doesn’t work or that it shouldn’t be administered to people, especially HCW and the elderly. And that is why you are getting backlash here since you are indeed asserting much more than the evidence shows and trying to use an absence of evidence as assertion for a positive claim on your part – which you cannot do. That is what Cochrane did and why we call it methodolatry and why it is wrong. The evidence exists – but not in robust RCT form.

  53. son 26 Oct 2011 at 3:30 pm

    First let me thank all the responders for taking the time to respond, despite the acerbity in some remarks.

    @nybgrus
    Re your reply to point 5. My point was not the one you reply to. My point was that about 90-95% of the decrease in infant (defined as 0-7 years of age) mortality occurred before childhood vaccinations programs began (at least in Sweden, excluding smallpox vaccination, which did not affect mortality).

    What you did reply to was my link to the Miller & Goldman study–a very interesting reply btw, but why not couch it as a a paper and send it to the relevant journal?

    Re point 6 you point me to Crislips 9Q9A, which discusses a totally unrelated issue (some points made by a Mr Mihailovic) having nothing to do with the hygiene and sanitation “revolution” of the late 19th and early 20th century, to which I do refer.

    Re Cochrane and RCT I do understand what you say, and as you point out in the following we agree on the point of not enough data. Thing is that I do not regard the flu vaccination data as enough convincing, while you regard it as a more or less definitive.

    The studies then: 1) The main finding the researchers made was that mortality did not decrease as it should assuming to the current hypothesis of flu vaccine effectiveness. The last phrase of the abstract, that you point too, is btw exactly the reasons why creationist constantly can attack science. It was totally meaningless, it detracted from the main point of the paper and it is just plain anxious. It is telling that you base your case on that instead of responding to the main findings of the paper.

    2) Yes, added it to show that the findings in 1) were not just a fluke.

    3) Yes, and we can start to infer a pattern here: that flu vaccine effects may be exaggerated due to confounding with a slew of other (respiratory) infections, malnutrition and so on.

    As you state “what we have done so far is inadequate and we can’t answer with a definitive answer as to what the effect size may actually be”. Yes, bingo! So why this constant yammering that we must flu vaccinate. We, do not know if it has any really good effect. What we do know is that it may hypothetically save some lives, but that total mortality figures do not show any decreased mortality in the age groups that hypothetically should get biggest benefit. We also do know that compared to historical mortality figures all this doom and gloom propaganda is pretty ludicrous. It just scares people. And talking about that I would recommend the book:

    “Dread: How Fear and Fantasy have Fueled Epidemics from the Black Death to the Avian Flu” by Philip Alcabes.

    And yes we can agree upon me interpreting the data as less conclusive than you do. To clarify a bit: my claim is that the contradicting data that exists is interesting enough and acceptably well researched to be reasonable. And that the mortality diminution gained by vaccination is minimal compared to historical mortality figures, but major in diminishing express morbidity.

    Finally I have never claimed that absence of data is proof–you put words in my mouth in yet another cheap rhetorical attempt. And I do notice that much of the replies I get are not addressing the exact issues I made. Yes, maybe I am just lousy at expressing myself, but hopefully not that badly. It is rather that most replies are very quarrelsome and plain attempts to misrepresent my opinions.

  54. ccbowerson 26 Oct 2011 at 3:59 pm

    “The last phrase of the abstract, that you point too, is btw exactly the reasons why creationist constantly can attack science.”

    Really? That is the reason? It isn’t because science conflicts with their ideology, so they attack the science? Are you really trying to argue that creationist really just want good science?

  55. nybgruson 26 Oct 2011 at 6:35 pm

    @s:

    You have completely missed my point (and yes, we both have not always adequately and accurately represented ourselves).

    And yes we can agree upon me interpreting the data as less conclusive than you do.

    No we don’t. We differ on what the ramifications and consequent course of action should be.

    To clarify a bit: my claim is that the contradicting data that exists is interesting enough and acceptably well researched to be reasonable.

    There is no contradictory data. There is no data that demonstrates an increased mortality. There is a paucity of data.

    Finally I have never claimed that absence of data is proof–you put words in my mouth in yet another cheap rhetorical attempt.

    That is exactly what you are doing, intentional or not. See my point right above – you take a paucity of data as contradictory data and assert that as positive evidence for your point. So no, there is no cheap rhetorical tactic here.

    And that the mortality diminution gained by vaccination is minimal compared to historical mortality figures, but major in diminishing express morbidity.

    You can’t accurately compare the data in the way you are attempting, since there are so many confounders to account for. But the point is that all you have demonstrated is that the effect size of flu vaccination has been:

    1) not thoroughly delineated
    2) probably less than we had previously thought

    That is not even remotely good enough to claim that we are overstressing flu vaccine (which is a subjective anyways) or that flue vaccine should not be administered. Even if the NNT for flu vaccine was 10,000 instead of 1,000 that would still be a good reason to vaccinate. And of course, especially since there isn’t such robust data, who do you think is the target of flu vaccine campaigns? Why those with the highest Bayesian likelihood of needing it! Elderly, very young, immunocompromised, and HCW.

    I get the flu vaccine pretty much only because I am a HCW. I like the added benefit that it will likely reduce and possibly prevent me from getting the flu as well since I don’t like having the flu!

    So what is your point here? You have demonstrated nothing we didn’t already know and have certainly given no evidence for halting flu vaccination. You could argue that since it seems the effect size will likely be smaller that low-risk populations shouldn’t be targeted and probably shouldn’t bother…. but that is already the case.

    And you haven’t addressed the basic sciences and clinical realities. Unless you would like to argue that an ICU patient or a frail elderly person in mild cardiac failure would somehow not have increased mortality and morbidity from contracting the flu?

  56. son 31 Oct 2011 at 3:57 pm

    Thanks for all the answers.

  57. djancakon 03 Apr 2013 at 5:42 pm

    “the EPA uses 75 years as life-long consumption”
    I can’t find a single thing from the EPA saying anything about this. Could somebody please cite the source for this information please? I’ve tried for half an hour and I’m giving up now.

  58. Paul-Jameson 04 Oct 2013 at 4:47 pm

    I think you did a good job clearing up misconceptions about the Flu… We provide FREE Flu vaccinations to all our Associates and insurance members and understand even though influenza is much more severe than a cold, it is preventable by getting an annual flu shot. The vaccination also helps to not spread the virus to family members as well as others. So this year we put together a video for our associates to help lighten the mood around getting vaccinated… It is a parody on the Kung Fu Fighting Song… “Kung Flu Fighting” take a look: http://youtu.be/nLJB7tatdzM

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