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?

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?

@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.

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.

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.

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

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.

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