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Old 23rd February 2013, 10:24 AM   #281
Skeptic Ginger
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Originally Posted by Estellea View Post
It's not even semi-random; this is a passive system.
Passive doesn't mean random or not random, it means the data is reported to the CDC, they don't actively collect it.


Originally Posted by Estellea View Post
It's true that the samples are mainly for epidemiological purposes but you fail to grasp that cultures aren't the only tests and other molecular assays are the tests of choice and can be done relatively rapidly. These can be used for diagnostic purposes but not necessary according to the CDC. I don't even know why this is even important especially when a good deal of those tests are also for other respiratory pathogen detection. I can't even tell why you are insisting that testing is randomised and why that is relevant.
This has nothing to do with the data bases differing. There are no specimens in the NREVSS data base that were collected for the purpose of sampling ILIs. The specimens come from providers ordering the tests because the patient needs a test.

With the NREVSS, lab data comes from participating labs report their results on TESTS ORDERED BY PROVIDERS. There's nothing random about it. The reason it matters most of the data comes from hospital labs is because most of the patients are in the hospital. The ILI sentinel providers are clinics and doctor's offices.


Originally Posted by Estellea View Post
The NREVSS is part of the influenza surveillance system. And yes, there are additional surveillance partners that also collect viral specimens and ILI activity. Why is this important other than for you to insist that you can't 'draw comparisons' between RSV activity and influenza activity when you can. I showed you this.
Being part of the surveillance system doesn't mean when you see this number:
Quote:
% positive for flu
it is an average between the sentinel site samples and the NREVSS samples. That % in the weekly reports that one can find all over the country from the county I live in to the states to the CDC comes very specifically from sampled ILIs, not from labs that are testing specimens on patients because a doctor ordered the test.
Quote:
volunteer sentinel providers send throat swabs from patients for laboratory testing


Originally Posted by Estellea View Post
[snipped false ad hom] I also showed you how the networks are used to compare the mortality of influenza and RSV in Thompson et al. for just one example. It's just plain preposterous and only seems to serve as more distraction from your OP.

Este
You haven't shown me anything. I haven't addressed that link yet because I'm still addressing the error you are making regarding interpreting the data you are looking at.

You have surveillance numbers here wrongly conflated.
Yes the NREVSS is part of the influenza surveillance system. Like I said, there are multiple data bases that go into the epidemiology model used to estimate influenza morbidity and mortality.
But the ILI sentinel surveillance system is a different data base and the %+ for flu is specifically sampled from the ILI surveillance sentinel providers. The specimens are not chosen because a provider orders a test needed to treat a patient.


BOTTOM LINE:

The NREVSS numbers don't apply to ILIs because they don't come from a sample of ILIs. Whatever RSV number you see is not the percent of RSV in the ILI numbers.

The % of ILIs + for flu come from a direct sampling of ILIs.
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Old 23rd February 2013, 10:30 AM   #282
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When the sentinel specimens are tested for more than just influenza, you get numbers like these Michigan numbers from February 21, 2013:
Quote:
Laboratory Surveillance (as of February 16): During February 10-16, 11 influenza A/H3 results (2SE,
4SW, 4C, 1N), 4 A/H1N1pdm09 (1SE, 2SW, 1C) and 5 B (1SE, 1SW, 3C) results were reported by
MDCH. For the 2012-13 season (starting Sept. 30, 2012), MDCH has identified 602 influenza results:
 Influenza A(H3): 483 (123SE, 168SW, 155C, 37N)
 Influenza A(H1N1)pdm09: 13 (1SE, 2SW, 2C, 2N)
 Influenza B: 106 (25SE, 19SW, 50C, 12N)
 Parainfluenza: 8 (3SW, 1C, 4N)
 RSV: 1 (1N)
The letters, C, N, SW etc refer to state regions. MDCH stands for Michigan Department of Community Health. That tells you these specimens were sent from the sentinel providers to the public health lab. These are not specimens from the hospital lab report. The overall % flu positive nationally during this week was just under 20%. I don't see the % + locally but it may be in the report somewhere.

Not all sentinel specimens are tested for everything in every public health lab because it costs too much.
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Old 23rd February 2013, 10:57 AM   #283
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Originally Posted by Skeptic Ginger View Post
A tweet in reply. Wow! I'm not on Twitter, guess I'll have to sign up. I'm honored.
You can email him at ben@badscience.net , no need to sign up to twitter just for that.
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Old 23rd February 2013, 11:47 AM   #284
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Originally Posted by Capsid View Post
Are virus culture methods still used? I would have thought PCR methods would be the assay of choice nowadays.
They are used somewhat although I don't know the proportion compared to molecular assays. Cultures are useful for stock cultures and samples for full genotyping.

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Old 23rd February 2013, 12:04 PM   #285
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Originally Posted by Estellea View Post
No kidding? You mean like Thompson et al. did? Perhaps you should write a letter to him and his group at the CDC to tell him that. I'm sure he'd appreciate it. It would also appear that the CDC recommends testing of hospitalised patients for influenza if it's suspected.
This study has already been addressed but I will address it again.

First, re testing patients for flu, did you notice the title: Guidance for Clinicians on the Use of Rapid Influenza Diagnostic Tests? That would be testing with a rapid screen you need not send to the lab.
Quote:
Influenza testing is recommended for hospitalized patients with suspected influenza. However, empiric antiviral treatment should be initiated as soon as possible without the need to wait for any influenza testing results
Re recommended, did you look at figure 1, the algorithm?
Quote:
Will the results of influenza virus testing*: change clinical care of the patient3 (especially for hospitalized patients and those with high risk conditions4) OR influence clinical practice for other patients?5
You seem to be over-reading the word, "recommended".

The sicker the patient, the more likely they are to have more definitive tests. And you have to consider provider ordering practices. I can guarantee you a sick infant is more likely to have a viral culture ordered than an older person who maybe already tested positive for flu with a rapid in-office screen. It's the human factor in the 'art' of medicine.



On to the study which I already posted about.

Note it is over a decade old. RSV may be an under-appreciated pathogen in the elderly, but it doesn't have that much impact on the CDC's flu burden models.

The key finding was:
Quote:
Influenza was associated with more deaths than RSV in all age groups except for children younger than 1 year. On average, influenza was associated with 3 times as many deaths as RSV.
This is consistent with current and even past influenza disease burden models.

You are reading too much into
Quote:
Statistical methods used to estimate deaths in the United States attributable to influenza have not accounted for RSV circulation.
Specifically, which statistical methods and what time frame?

Quote:
using national viral surveillance data for the 1976-1977 through 1998-1999 seasons were used to estimate influenza-associated deaths. Influenza- and RSV-associated deaths were simultaneously estimated for the 1990-1991 through 1998-1999 seasons.
So, the time frame they refer to is from 40 years ago to 12 years ago.


The discussion:
Quote:
Mortality associated with influenza can vary dramatically by season and models developed to assess influenza-associated mortality date back to 1847.28 These approaches have been feasible because well-defined peaks in deaths occur in association with influenza outbreaks in temperate countries. In the recent past, the CDC has used a linear regression model, applied to either complete national mortality data or more immediately available mortality surveillance data from 122 cities, to estimate annual deaths associated with influenza.1- 2 The influenza and RSV model presented in this study will be used to provide future estimates of influenza-associated mortality in the United States, because the model permits estimates of influenza subtype-specific mortality and also simultaneously estimates RSV-associated mortality.
Flu varies dramatically, note the bolded sentence. RSV does not vary much from season to season. Flu models have used the variation to recognize flu outbreaks and disease burden. Where do these study findings challenge that model?


Consistent with what I've said:
Quote:
The influenza and RSV model confirmed that influenza A(H3N2) viruses were associated with the highest attributable mortality rates, followed by RSV, influenza B, and influenza A(H1N1) viruses. The annual effect of RSV on mortality was relatively stable,
If you total the flu strains, they significantly exceed the RSV burden. In addition, nothing in this research suggests using ILIs and P&I mortality is not reflecting influenza burden.

The authors are merely concluding some RSV in the elderly is going unrecognized. They did not find the flu burden models to be significantly faulty.



Quote:
Pneumonia and influenza deaths are highly correlated with the circulation of influenza, and these estimates are useful for monitoring year-to-year trends and variability in the severity of influenza seasons. However, this death category underestimates the total burden of influenza because many deaths are caused by other secondary complications of influenza (eg, congestive heart failure).7 Traditionally, all-cause deaths have been used to estimate the total burden of influenza on mortality.1- 2 However, this death category is also not ideal because it includes deaths that are not causally linked with respiratory viral infections. Therefore, we analyzed underlying respiratory and circulatory deaths to provide a more specific estimate of the total burden of influenza and RSV on mortality. Our estimate of annual mean influenza-associated underlying respiratory and circulatory deaths was 36 155 (29% lower than the annual mean all-cause estimate).
What they are saying there is, changes in 'all cause mortality' has noise in it as an estimate of flu deaths. No one is saying 'all cause mortality' is all flu. A change in the death rate during peak flu outbreaks only goes up 2-4% or so above the normal total death rate.

Quote:
Although the importance of RSV among young children is well recognized,41- 42 we found that more than 78% of RSV-associated underlying respiratory and circulatory deaths occured among persons aged 65 years or older.
I addressed this already. There's a larger number of significant/more severe RSV infections in the elderly than in children. But that doesn't change the fact there's a much larger number of flu infections than RSV in the elderly, and, nothing in this paper is particularly shocking revelation that flu numbers have been way off. It's the opposite, it supports the current flu models which use spikes in ILIs and P&I deaths in the model because RSV outbreaks are more stable.


There is no smoking gun here.
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Old 23rd February 2013, 12:05 PM   #286
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Originally Posted by zooterkin View Post
You can email him at ben@badscience.net , no need to sign up to twitter just for that.
Thanks, I plan to email him. I tweeted him back but have no idea if he even read it.
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Old 23rd February 2013, 12:11 PM   #287
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Originally Posted by Capsid View Post
Are virus culture methods still used? I would have thought PCR methods would be the assay of choice nowadays.
From Guidance for Clinicians on the Use of Rapid Influenza Diagnostic Tests
Quote:
The reference standards for laboratory confirmation of influenza virus infection are reverse transcription-polymerase chain reaction (RT-PCR) or viral culture. RIDTs can yield results in a clinically relevant time frame, i.e., approximately 15 minutes or less. However, RIDTs have limited sensitivity to detect influenza virus infection and negative test results should be interpreted with caution given the potential for false negative results.
Most labs are switching over to PCR antigen probes for a number of pathogen diagnostic tests rather than cultures because the results are obtained faster.

The data, whether obtained by culture or PCR, are both in the data reported by the labs in the NREVSS data base. It still comes from specimens that providers have ordered diagnostic tests on for their patient's treatment.
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Old 26th February 2013, 02:04 PM   #288
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Originally Posted by kellyb View Post
Ok, Ginger.
If you admit (and you probably don't) that the CDC/ACIP has revised their communications, what do you make of this?


http://www.cdc.gov/flu/about/qa/disease.htm

"Over a period of 30 years, between 1976 and 2006, estimates of flu-associated deaths in the United States range from a low of about 3,000 to a high of about 49,000 people."

Where does the 3K figure come from? Where does the almost 50K number come from?
I know you expect a smoking gun here, but you won't find it. The methodology for how the CDC estimates flu burden has been posted more than once in this thread. Instead of looking at the disease models they use incorporating multiple data bases, you've been hung up on the RSV is under-counted and I'm guessing just haven't looked at the model the CDC uses.

Overview of Influenza Surveillance in the United States
Quote:
Together, the five categories of influenza surveillance are designed to provide a national picture of influenza activity. Human infections with novel influenza A viruses, pneumonia and influenza mortality from the 122 Cities Mortality System, and influenza-associated pediatric deaths are reported on a national level only. FluSurv-NET data provides population-based, laboratory-confirmed estimates of influenza-related hospitalizations but are reported from limited geographic areas. Outpatient influenza-like illness and laboratory data are reported on a national level and by Department of Health and Human Services region. The state and territorial epidemiologists' reports of the geographic spread of influenza activity and the ILI activity indicator display state-level information.
Estimating Seasonal Influenza-Associated Deaths in the United States: CDC Study Confirms Variability of Flu
Quote:
These are some of the reasons that CDC and other public health agencies in the United States and other countries use statistical models to estimate the annual number of seasonal flu-related deaths. ... CDC estimates of annual influenza-associated deaths in the United States are made using well-established scientific methods that have been reviewed by scientists outside of CDC.

...An August 27, 2010 MMWR report entitled “Thompson MG et al. Updated Estimates of Mortality Associated with Seasonal Influenza through the 2006-2007 Influenza Season. MMWR 2010; 59(33): 1057-1062.," provides updated estimates of the range of flu-associated deaths that occurred in the United States during the three decades prior to 2007. CDC estimates that from the 1976-1977 season to the 2006-2007 flu season, flu-associated deaths ranged from a low of about 3,000 to a high of about 49,000 people. ...

...The 36,000 estimate was presented in a 2003 study by CDC scientists published in the Journal of the American Medical Association (JAMA), using similar statistical modeling techniques, but only refers to a period from 1990-91 through 1998-99. During those years, the number of estimated deaths ranged from 17,000 to 52,000, with an average of about 36,000. The JAMA study also looked at seasonal influenza-associated deaths over a 23 year period, from 1976-1977 and 1998-1999. During that period, estimates of respiratory and circulatory influenza-associated deaths ranged from about 5,000 to about 52,000, with an average of about 25,000. While the 36,000 number is often cited, it's important to note that during that decade, influenza A (H3N2) was the predominant virus during most of the seasons, and H3N2 influenza viruses are typically associated with higher death rates. CDC believes that the range of deaths over the past 31 years (~3,000 to ~49,000) is a more accurate representation of the unpredictability and variability of flu-associated deaths.
That's pretty specific as to where the numbers come from.

Next post, those two cited studies.
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Old 26th February 2013, 02:16 PM   #289
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Originally Posted by Skeptic Ginger View Post
I know you expect a smoking gun here, but you won't find it. The methodology for how the CDC estimates flu burden has been posted more than once in this thread. Instead of looking at the disease models they use incorporating multiple data bases, you've been hung up on the RSV is under-counted and I'm guessing just haven't looked at the model the CDC uses.
Yes it has been posted along with the criticisms of why and how they over-estimate. Being "hung up" on RSV has nothing to do with it so you know what you can do with your strawman.
Quote:
A model which even the lead author admits over-estimates flu mortalities. Perhaps you should stick to one thread at a time that you flail in.

Este
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Old 26th February 2013, 02:44 PM   #290
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Estimates of Deaths Associated with Seasonal Influenza --- United States, 1976--2007

I'm guessing we can get right to the point here since (2) in this quote cites the 2003 study that's been brought up twice in the thread:
Quote:
The findings in this report are subject to at least four limitations. First, the models do not account for cocirculating pathogens such as respiratory syncytial virus (RSV). Future research should replicate and extend models that distinguish between deaths associated with influenza versus RSV (2).
The problem here is about how much impact. Just saying there is an impact doesn't mean it is very significant.

Well it turns out the 2nd reference in the above post is the 2003 study: Mortality Associated With Influenza and Respiratory Syncytial Virus in the United States.

So you are essentially claiming the CDC does not use a valid estimate of flu burden when they themselves address the RVS proportion.

We are back to the same issue, you seem to think the RSV proportion is a large part of the flu burden estimate (not to be confused with the absolute RSV disease burden).

Quote:
The influenza and RSV model confirmed that influenza A(H3N2) viruses were associated with the highest attributable mortality rates, followed by RSV, influenza B, and influenza A(H1N1) viruses. The annual effect of RSV on mortality was relatively stable, although the numbers of deaths associated with influenza viruses varied substantially,
Flu burden high, RSV burden stable. So how many of those 3,000 to 49,000 deaths attributed to flu were really RSV deaths?


From table 3 in that study, total average P&I deaths during the 90s attributed to flu was 8,000 and 2,700 to RSV. From table 1 in the study the CDC used that had the RSV caveat, the total flu P&I deaths in the 90s averaged ~7,000.

So here is a key number, P&I deaths counted as flu deaths, and the study that supposedly doesn't account for the RSV proportion of the flu burden has a lower number for P&I flu deaths than the study that calculated the number of flu and RSV P&I deaths as separate numbers.


I'll spend some more time on this later.
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Old 26th February 2013, 03:02 PM   #291
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Originally Posted by Skeptic Ginger View Post
I'll spend some more time on this later.
You needn't bother as you can't seem to grasp that the Thompson et al. studies used to generate flu-related mortalities is so highly flawed that the author himself can't even defend it yet it's used instead of adequately surveying the population and constructing a better model that reflects flu-related mortalites with more precision.

You also needn't bother because you are so woefully dishonest and can't even give those of us the courtesy, who have bothered to contribute here, of reading the reviews that you say aren't right. And woefully dishonest when you accuse Kellyb of derailing the thread yet here you are with the most painful hand-waving and mental contortions I've seen in a while to distract from the fact that you either didn't read (my guess) or can't understand the Cochrane Reviews you say are not right. Your tactics are an affront to sceptics and the medical profession.

Get to the damn point already will you? Dr. Goldacre isn't going to swoop in and save you.

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Old 26th February 2013, 04:13 PM   #292
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Originally Posted by Estellea View Post
You needn't bother as you can't seem to grasp that the Thompson et al. studies used to generate flu-related mortalities is so highly flawed that the author himself can't even defend it yet it's used instead of adequately surveying the population and constructing a better model that reflects flu-related mortalites with more precision.

You also needn't bother because you are so woefully dishonest and can't even give those of us the courtesy, who have bothered to contribute here, of reading the reviews that you say aren't right. And woefully dishonest when you accuse Kellyb of derailing the thread yet here you are with the most painful hand-waving and mental contortions I've seen in a while to distract from the fact that you either didn't read (my guess) or can't understand the Cochrane Reviews you say are not right. Your tactics are an affront to sceptics and the medical profession.

Get to the damn point already will you? Dr. Goldacre isn't going to swoop in and save you.

Este
From table 3 in that study, total average P&I deaths during the 90s attributed to flu was 8,000 and 2,700 to RSV. From table 1 in the study the CDC used that had the RSV caveat, the total flu P&I deaths in the 90s averaged ~7,000.

Where is the flaw exactly?

A comment by the author on limitations? Is that your entire case?

Research 101:
Quote:
Claiming limitiations is a subjective process because you must evaluate the impact of those limitations. Don't just list key weaknesses and the magnitude of a study's limitations. To do so diminishes the validity of your research because it leaves the reader wondering whether, or in what ways, limitation(s) in your study may have impacted the findings and conclusions. Limitations require a critical, overall appraisal and interpretation of their impact. You should answer the question: do these problems with errors, methods, validity, etc. eventually matter and, if so, to what extent?
Whether commented on or not in the limitations, one still needs to ask: what is the impact of that limitation on the study's results. I don't see where you've done that. I'm not trying to insult you, I've been trying to address your belief the CDC overestimates flu burden and I'm not finding the comment in 'limitations' or Thomson, et al supports that assertion.
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Old 26th February 2013, 05:01 PM   #293
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The Epidemiology of Influenza and Its Control
Quote:
More recently, the US Centers for Disease Control and Prevention (CDC) has used an approach to measure hospitalization and mortality burden based on a new generation of seasonal regression models integrating laboratory surveillance data on influenza and respiratory syncytial virus (RSV) [5, 11]. In such models, winter seasonal increases in deaths or hospitalizations are directly proportional to the magnitude of respiratory virus activity. In the USA between 1980 and 2001, Thompson et al. [5, 11] estimated that seasonal influenza epidemics were associated with 17 deaths per 100,000 on average (range 6–28 per 100,000) depending on the severity of the circulating strains. Reassuringly, different model approaches, with and without the quantification of the number of viral isolates, yield similar average estimates of the influenza mortality burden in the USA [13, 50, 51]. Estimates from Europe and Canada are similar to those from the USA [44, 52, 53]. Viral surveillance data with the integration of hospitalization or death indicators are particularly useful for the study of influenza in the tropics where there is less seasonality....


...One controversy in the literature concerns the relative contributions of influenza and RSV to the winter increase in respiratory hospitalizations and deaths, especially among seniors. The current CDC modeling approach simultaneously estimates the influenza and RSV burden by correlating periods of excess mortality with their respective period and magnitude of viral activity [5]. In the overall US population, the CDC investigators estimate that the average seasonal RSV burden is approximately one-third of that of influenza for all seasons during the 1990s. However, the relative contribution of RSV and influenza varies greatly with age.
I.e. Thompson's data.

WHO: A Practical Guide for Designing and Conducting Influenza Disease Burden Studies; 2009
Quote:
Since the respiratory syncytial virus (RSV) is known to cocirculate with influenza viruses and affect morbidity and mortality among both young children and the elderly (26-29). RSV data in numbers and proportion of specimens tested positive for RSV will also be collected and included in the statistical models.
But you think because of a sentence in "limitations" this isn't done at all by the CDC when they come up with their flu burden numbers.

Well let's look closer: From the CDC estimate of flu burden 3,000 to 49,000 deaths:
Quote:
Using methods published previously (2,3), CDC estimated the numbers and rates of influenza-associated deaths by virus type and subtype by using Poisson regression models that incorporated weekly national respiratory viral surveillance data. Weekly influenza test results by virus type and subtype were provided by approximately 80 World Health Organization (WHO) and 70 National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories in the United States (8). Prominent influenza type and subtype were defined as at least 20% of all isolates that were tested in that season. Mortality data were obtained from the National Vital Statistics System and reflect the underlying cause of death recorded on death certificates (9). Deaths were categorized using the International Classification of Diseases eighth revision (ICD-8), ninth revision (ICD-9), or 10th revision (ICD-10), as appropriate. Weekly estimates of the U.S. population by age group were used as part of the model to correspond to the weekly viral surveillance estimates. All data for deaths with underlying pneumonia and influenza causes and respiratory and circulatory causes were actual counts based on the death certificate ICD codes. To estimate the proportion of deaths that were influenza associated, the average annual number of deaths estimated by the model was divided by the average annual counts of death with underlying pneumonia and influenza causes and respiratory and circulatory causes.
And from the WHO guideline on estimating flu burden:
Quote:
Annex 12: Approach 6 - Poisson Regression Method
(a) Poisson regression (assumed weekly data to be used)
[formula snipped]
where for each week index t (t = 1,2,...,n), observation Yt follows Poisson distribution, E(Yt) is the expected numbers of health outcome; Z it, Z2t,...,Zqt are the covariates for trends, seasonality, temperature, relative humidity and proportion of positive results tested for RSV; Xt is the weekly proportion of positive results tested for influenza; β1 , β2 ,..., βq and θ are the estimated parameters for respective covariates and α is an intercept of the model.
The CDC is subtracting RSV from the flu deaths in their totals regardless of what Thompson, et al's concerns were in the study limitations. Perhaps his reference to "the models", (plural), not accounting for RSV, he is referring to some of the data but not necessarily all of the conclusions.

Quote:
Debate will continue regarding the most appropriate statistical models and cause of death categories to use in estimating the number of influenza-associated deaths (1,7). This study's provision of estimates for more narrow (pneumonia and influenza causes) and more broad (respiratory and circulatory causes) categories continues the strategy of comparing and contrasting results from different models as advocated by CDC (1--3) and others (7).
I'll have to look further into the debate on the statistical models in order to understand the limitations the paper is referring to.
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Old 26th February 2013, 06:56 PM   #294
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Originally Posted by kellyb View Post
Ok, Ginger.
If you admit (and you probably don't) that the CDC/ACIP has revised their communications, what do you make of this?


http://www.cdc.gov/flu/about/qa/disease.htm

"Over a period of 30 years, between 1976 and 2006, estimates of flu-associated deaths in the United States range from a low of about 3,000 to a high of about 49,000 people."

Where does the 3K figure come from? Where does the almost 50K number come from?
Originally Posted by Skeptic Ginger View Post
From table 3 in that study, total average P&I deaths during the 90s attributed to flu was 8,000 and 2,700 to RSV. From table 1 in the study the CDC used that had the RSV caveat, the total flu P&I deaths in the 90s averaged ~7,000.

Where is the flaw exactly?

A comment by the author on limitations? Is that your entire case?

Research 101:Whether commented on or not in the limitations, one still needs to ask: what is the impact of that limitation on the study's results. I don't see where you've done that. I'm not trying to insult you, I've been trying to address your belief the CDC overestimates flu burden and I'm not finding the comment in 'limitations' or Thomson, et al supports that assertion.
I put Kelly's question in since you are now distracting from your distraction. Where does the 3K and nearly 50K figures come from? All you are doing is more appeal to authority without even being remotely inquisitive or critical of the model used to generate the CDC flu-related mortalities. To give you an example, did you even bother to read the commentaries for the Thompson et al. JAMA study? When I see commentaries in a PubMed citation, my curiosity is piqued. One of us also gave you this link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1309667/ which highlights the most glaring deficit of the Thompson et al. models.
Quote:
Well let's look closer: From the CDC estimate of flu burden 3,000 to 49,000 deaths:
You don't even know what a Poisson regression model is so please stop trying to blow smoke up my bum. Besides that, you're conflating discussions of morbidity versus mortality with regards to properly controlling for RSV.
Quote:
I'll have to look further into the debate on the statistical models in order to understand the limitations the paper is referring to.
Ya think you should have done that before coming out of the gate so cocksure?

So I guess in addition to you never getting to the point of critiquing the Cochrane Reviews, you're not going to tell us how the CDC is coming up with the 3K to ~50K flu-related mortality range. I'm not interested in your appeals to authority; explain how they come to ~50K for the upper range.

Este
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Old 26th February 2013, 10:29 PM   #295
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First, Doshi's paper since I haven't gotten around to that one yet.

Doshi makes the same false charge as Jefferson and I think I see the pattern now:
Quote:
But why are flu and pneumonia bundled together?
I remain floored why Doshi and Jefferson both make this error. Yes, those numbers are collected as part of the flu surveillance system, but the raw numbers are not what the CDC claims are flu deaths.

He goes on to this completely out of context argument:
Quote:
Meanwhile, according to the CDC's National Center for Health Statistics (NCHS), “influenza and pneumonia” took 62 034 lives in 2001—61 777 of which were attributed to pneumonia and 257 to flu, and in only 18 cases was flu virus positively identified. Between 1979 and 2002, NCHS data show an average 1348 flu deaths per year (range 257 to 3006).
Here's the raw mortality data Doshi refers to, the numbers are from death certificates:
Quote:
2001: Influenza and pneumonia (J10-J18) 62,034
Influenza (J10-J11) 267
Death certificate coding:
Quote:
The ICD provides the basic guidance used in virtually all countries to code and classify causes of death. It provides not only disease, injury, and poisoning categories but also the rules used to select the single underlying cause of death for tabulation from the several diagnoses that may be reported on a single death certificate,

Summing up Doshi's case:
Quote:
Thus the much publicised figure of 36 000 is not an estimate of yearly flu deaths, as widely reported in both the lay and scientific press, but an estimate—generated by a model—of flu-associated death.
That's his criticism? You get flu and die from secondary pneumonia and Doshi doesn't think that should count as flu burden?

It's a stupid argument. His whole argument is bull.

But it's worse than that. He is simply ignores the entire model the CDC uses to estimate flu deaths and, based on what gets reported on death certificates, regardless of all the other data that the CDC uses, proclaims the CDC is lying to everyone.

Quote:
If flu is in fact not a major cause of death, this public relations approach is surely exaggerated. Moreover, by arbitrarily linking flu with pneumonia, current data are statistically biased. Until corrected and until unbiased statistics are developed, the chances for sound discussion and public health policy are limited.
To criticize the CDC's flu mortality burden without actually looking at the CDC's model is just plain nuts. Where does Doshi support his assertion death certificate codes, sans even looking at the CDC flu surveillance data is a valid criticism? He's condemned the whole flu surveillance department of the CDC as being in bed with and/or duped by drug companies who make flu drugs and vaccines.


It's making more sense now. Both of them, Doshi and Jefferson are Big Pharma CTers at least to some degree. Goldacre has valid criticisms about the influence of Big Pharma on medical research. But these two flu risk naysayers are well over the line with the CT stuff discounting thousands of scientists and medical providers around the world who work in the influenza field.
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Old 27th February 2013, 02:49 AM   #296
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SG, do you admit that the CDC has revised its flu estimates (in terms of morbidity and mortality for the US) since Doshi and Jefferson ( and the CCr) made their criticisms?
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Old 27th February 2013, 06:21 AM   #297
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Originally Posted by Skeptic Ginger View Post
First, Doshi's paper since I haven't gotten around to that one yet.

Doshi makes the same false charge as Jefferson and I think I see the pattern now:I remain floored why Doshi and Jefferson both make this error. Yes, those numbers are collected as part of the flu surveillance system, but the raw numbers are not what the CDC claims are flu deaths.
Oh gosh, I seemed to have missed the part where you are now an expert biostatitician. Dr. Doshi isn't claiming that the raw numbers are what the CDC uses; he is criticising the Thompson model that uses them in their formula which ultimately overestimates flu-related deaths.

Quote:
He goes on to this completely out of context argument:

Here's the raw mortality data Doshi refers to, the numbers are from death certificates:

Death certificate coding:


Summing up Doshi's case:
That's his criticism? You get flu and die from secondary pneumonia and Doshi doesn't think that should count as flu burden?
Um no, that isn't his criticism. Look again:
Quote:
In a written statement, CDC media relations responded to the diverse statistics: “Typically, influenza causes death when the infection leads to severe medical complications.” And as most such cases “are never tested for virus infection...CDC considers these [NCHS] figures to be a very substantial undercounting of the true number of deaths from influenza. Therefore, the CDC uses indirect modelling methods to estimate the number of deaths associated with influenza.”

CDC's model calculated an average annual 36 155 deaths from influenza associated underlying respiratory and circulatory causes (JAMA 2003;289: 179-86 [PubMed]). Less than a quarter of these (8097) were described as flu or flu associated underlying pneumonia deaths. Thus the much publicised figure of 36 000 is not an estimate of yearly flu deaths, as widely reported in both the lay and scientific press, but an estimate—generated by a model—of flu-associated death.
It's not that secondary pneumonias that are precipitated by a primary influenza shouldn't be counted, it's the fact that secondary pneumonias that aren't necessarily precipitated by a primary influenza are also counted as flu-related deaths because most of them aren't antigenically-confirmed.
Quote:
It's a stupid argument. His whole argument is bull.
Yea well I guess if you don't have a grasp of statistics and you are desperately clinging to beliefs you would have to claim that.

Quote:
But it's worse than that. He is simply ignores the entire model the CDC uses to estimate flu deaths and, based on what gets reported on death certificates, regardless of all the other data that the CDC uses, proclaims the CDC is lying to everyone.
Ignores the "CDC model"? Duh, his entire criticism is based upon the model used and the inconsistencies between it and the mortality statistics.
Quote:
Meanwhile, according to the CDC's National Center for Health Statistics (NCHS), “influenza and pneumonia” took 62 034 lives in 2001—61 777 of which were attributed to pneumonia and 257 to flu, and in only 18 cases was flu virus positively identified. Between 1979 and 2002, NCHS data show an average 1348 flu deaths per year (range 257 to 3006).
And again, the lead CDC author Thompson states:
Quote:
William Thompson of the CDC's National Immunization Program (NIP), and lead author of the CDC's 2003 JAMA article, explained that “influenza-associated mortality” is “a statistical association between deaths and viral data available.” He said that an association does not imply an underlying cause of death: “Based on modelling, we think it's associated. I don't know that we would say that it's the underlying cause of death.”
Even he says that being a "statistical association" that estimates flu-related mortalities can't actually be a basis for making the claim that they were all, in fact, flu-related.

Quote:
To criticize the CDC's flu mortality burden without actually looking at the CDC's model is just plain nuts. Where does Doshi support his assertion death certificate codes, sans even looking at the CDC flu surveillance data is a valid criticism? He's condemned the whole flu surveillance department of the CDC as being in bed with and/or duped by drug companies who make flu drugs and vaccines.
But he did examine the Thompson model and compare that to the national mortality stats and they aren't consistent.
Quote:
Before 2003 CDC said that 20 000 influenza-associated deaths occurred each year. The new figure of 36 000 reported in the January 2003 JAMA paper is an estimate of influenza-associated mortality over the 1990s. Keiji Fukuda, a flu researcher and a co-author of the paper, has been quoted as offering two possible causes for this 80% increase: “One is that the number of people older than 65 is growing larger...The second possible reason is the type of virus that predominated in the 1990s [was more virulent].”

However, the 65-plus population grew just 12% between 1990 and 2000. And if flu virus was truly more virulent over the 1990s, one would expect more deaths. But flu deaths recorded by the NCHS were on average 30% lower in the 1990s than the 1980s.
Go ahead and wow me with your stats expertise and explain these inconsistencies. Explain to me how it isn't a good thing to more accurately represent flu-related mortalities with a different model based upon more rigorous testing. Which is what Doshi is saying.

Quote:
It's making more sense now. Both of them, Doshi and Jefferson are Big Pharma CTers at least to some degree. Goldacre has valid criticisms about the influence of Big Pharma on medical research. But these two flu risk naysayers are well over the line with the CT stuff discounting thousands of scientists and medical providers around the world who work in the influenza field.
But of course, paint them as conspiracy theorists and you can continue being lazy and not bothering to read the reviews and critically analysing them. But you have a big problem with that, Osterholm et al. has found the same problems with vaccine effectiveness and policy implementation that Jefferson has found. And other groups (e.g. Simonsen et al.) have also found inconsistencies with flu-related mortality claims and statistics that Doshi has criticised.

Este
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Old 27th February 2013, 07:43 AM   #298
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Originally Posted by Estellea View Post


Quote:
Quote:
In a written statement, CDC media relations responded to the diverse statistics: “Typically, influenza causes death when the infection leads to severe medical complications.” And as most such cases “are never tested for virus infection...CDC considers these [NCHS] figures to be a very substantial undercounting of the true number of deaths from influenza. Therefore, the CDC uses indirect modelling methods to estimate the number of deaths associated with influenza.”

CDC's model calculated an average annual 36 155 deaths from influenza associated underlying respiratory and circulatory causes (JAMA 2003;289: 179-86 [PubMed]). Less than a quarter of these (8097) were described as flu or flu associated underlying pneumonia deaths. Thus the much publicised figure of 36 000 is not an estimate of yearly flu deaths, as widely reported in both the lay and scientific press, but an estimate—generated by a model—of flu-associated death.
It's not that secondary pneumonias that are precipitated by a primary influenza shouldn't be counted, it's the fact that secondary pneumonias that aren't necessarily precipitated by a primary influenza are also counted as flu-related deaths because most of them aren't antigenically-confirmed.
The above is a non sequitur. The fact that "the CDC uses indirect modelling methods to estimate the number of deaths associated with influenza." does not imply that "secondary pneumonias that aren't necessarily precipitated by a primary influenza are also counted as flu-related deaths"

Take the advice of someone with professional training and experience in statistics and demographics: Without logic, data is useless.
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Old 27th February 2013, 07:59 AM   #299
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Since pneumonia is the number one killer, why isn't everyone vaccinated against it?

http://www.cdc.gov/features/pneumonia/
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Old 27th February 2013, 08:07 AM   #300
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Originally Posted by Perpetual Student View Post
The above is a non sequitur. The fact that "the CDC uses indirect modelling methods to estimate the number of deaths associated with influenza." does not imply that "secondary pneumonias that aren't necessarily precipitated by a primary influenza are also counted as flu-related deaths"

Take the advice of someone with professional training and experience in statistics and demographics: Without logic, data is useless.
The fact that pneumonias without a confirmed primary influenza are being counted and rolled into the formula is absolutely germane to the criticism of flu-mortality stats. It is also more than implied as the Thompson et al. model is wildly inconsistent with hard mortality stats. So tell me, where is the logic in that?
ETA: Add to that the fact that the influenza vaccine is not efficacious in the elderly but the CDC claiming that flu-related mortalities have been reduced in this cohort due to vaccination and we have another layer of inconsistency.

Este

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Old 27th February 2013, 08:24 AM   #301
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Originally Posted by r-j View Post
Since pneumonia is the number one killer, why isn't everyone vaccinated against it?
Because pneumonia is a condition with multiple possible causes, not a single disease.
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Old 27th February 2013, 08:29 AM   #302
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I know, but the link I provided explains that. And why vaccines prevent pneumonia. The flu is not even the main risk factor in pneumonia.
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Old 27th February 2013, 08:34 AM   #303
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Perpetual Student, Thompson et al. makes the assumption that flu-related mortalities are under-estimated and builds their model on that premise, fair enough. However:
Quote:
CDC's model calculated an average annual 36 155 deaths from influenza associated underlying respiratory and circulatory causes (JAMA 2003;289: 179-86 [PubMed]). Less than a quarter of these (8097) were described as flu or flu associated underlying pneumonia deaths. Thus the much publicised figure of 36 000 is not an estimate of yearly flu deaths, as widely reported in both the lay and scientific press, but an estimate—generated by a model—of flu-associated death.
And:
Quote:
Meanwhile, according to the CDC's National Center for Health Statistics (NCHS), “influenza and pneumonia” took 62 034 lives in 2001—61 777 of which were attributed to pneumonia and 257 to flu, and in only 18 cases was flu virus positively identified. Between 1979 and 2002, NCHS data show an average 1348 flu deaths per year (range 257 to 3006).
Logic and statistics dictate that this is a wide margin of error and/or uncertainty. Thompson et al.'s model is multiplicative of deaths attributed to flu rather than additive and in some years deaths are actually underestimated while in most, overestimated. This model is simply built on too many assumptions and apparently an inappropriate formula. There is nothing wrong with estimating with modelling as long as that model is built upon and tested against more precise data.

Este
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Old 27th February 2013, 08:43 AM   #304
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Originally Posted by r-j View Post
Since pneumonia is the number one killer, why isn't everyone vaccinated against it?

http://www.cdc.gov/features/pneumonia/
In the UK, the pneumococcal vaccine (PCV) (as well as vaccines for some other illnesses that can cause pneumonia) is part of the childhood immunisation schedule. Elderly people and those is high risk groups are also offered this, or a similar pneumococcal vaccine (PPV).

http://www.nhs.uk/Conditions/vaccina...ccination.aspx

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Old 27th February 2013, 10:34 AM   #305
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Originally Posted by r-j View Post
Since pneumonia is the number one killer, why isn't everyone vaccinated against it?

http://www.cdc.gov/features/pneumonia/
I'm not sure I understand what you mean by your question. Do you mean why don't people get the vaccines that are recommended? Or why aren't all these vaccines recommended for everyone?

Quote:
In the United States, there are several vaccines that prevent infection by bacteria or viruses that may cause pneumonia. These vaccines include:
Pneumococcal,
Haemophilus influenzae type b (Hib),
Pertussis (whooping cough),
Varicella (chickenpox),
Measles, and
Influenza (flu) vaccine.
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Old 27th February 2013, 10:49 AM   #306
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Originally Posted by Estellea View Post
Perpetual Student, Thompson et al. makes the assumption that flu-related mortalities are under-estimated and builds their model on that premise, fair enough. However:

And:

Logic and statistics dictate that this is a wide margin of error and/or uncertainty. Thompson et al.'s model is multiplicative of deaths attributed to flu rather than additive and in some years deaths are actually underestimated while in most, overestimated. This model is simply built on too many assumptions and apparently an inappropriate formula. There is nothing wrong with estimating with modelling as long as that model is built upon and tested against more precise data.

Este
You continue to ignore how flu burden is actually calculated, asserting the assumptions are wrong and the formula inappropriate.

There is no convincing evidence or scientific consensus that is the case. There are a couple researchers who challenge the epidemiology model out of how many? It doesn't make their objections correct.

Doshi's whole premise, death certificate coding doesn't fit the data, ignores the entire reason why flu is not listed on many death certificates.

Doshi and Jefferson both have Big Pharma CT beliefs that have been expressed in their public opinions.
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Old 27th February 2013, 10:55 AM   #307
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Originally Posted by Estellea View Post
The fact that pneumonias without a confirmed primary influenza are being counted and rolled into the formula is absolutely germane to the criticism of flu-mortality stats.
Again, ignoring the facts and asserting baseless estimates are being used.


Originally Posted by Estellea View Post
It is also more than implied as the Thompson et al. model is wildly inconsistent with hard [cherry picked] mortality stats [without acknowledging, let alone considering why flu is rarely coded as a primary cause on a death certificate]. So tell me, where is the logic in that?
ftfy.


Originally Posted by Estellea View Post
ETA: Add to that the fact that the influenza vaccine is not efficacious in the elderly but the CDC claiming that flu-related mortalities have been reduced in this cohort due to vaccination and we have another layer of inconsistency.

Este
Which has been addressed by the CDC and which you continue to assert it hasn't.
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Old 27th February 2013, 11:30 AM   #308
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Originally Posted by Skeptic Ginger View Post
You continue to ignore how flu burden is actually calculated, asserting the assumptions are wrong and the formula inappropriate.

There is no convincing evidence or scientific consensus that is the case. There are a couple researchers who challenge the epidemiology model out of how many? It doesn't make their objections correct.

Doshi's whole premise, death certificate coding doesn't fit the data, ignores the entire reason why flu is not listed on many death certificates.

Doshi and Jefferson both have Big Pharma CT beliefs that have been expressed in their public opinions.
FFS I'm directly addressing the problems with the way the CDC estimates flu mortalities. While I'm not a statistics expert, I can pick out problems and also have the know how and appreciation for others' critiques of this particular model. All you have done is argument from assertion and completely mangle Doshi's critique either out of ignorance, willful blindness or both. You haven't explained, at all, how this model is correct aside from "the CDC says so". Pathetic.

As for Doshi and Jefferson's "Big Pharma CT beliefs", how do you reconcile the fact that the CDC has finally acquiesced that flu vaccines are not efficacious in the elderly in spite of a good antigenic match and Jefferson's Cochrane review with your own confirmation bias? As for flu mortality estimates, nothing, absolutely nothing except reliance upon authority and popularity. How is the fact that it is multiplicative rather than additive not a problem?

Este
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Old 27th February 2013, 11:34 AM   #309
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Originally Posted by Skeptic Ginger View Post
Again, ignoring the facts and asserting baseless estimates are being used.

ftfy.

Which has been addressed by the CDC and which you continue to assert it hasn't.
Go ahead, show me where the mortality stats are cherry-picked. You see the problem is is that the CDC doesn't address this as the model they use is flawed, even by the lead author's own admission. YOU tell me why this is an appropriate model to use. You do this in every thread you get in over your head with.

By the way, when do you suppose you'll get around to reading those Cochrane reviews and explaining how the flu mortality range was obtained and why it was changed? From where I'm standing, all you are doing is arguing around the hard questions, ones that you brought up no less.

Este

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Old 27th February 2013, 12:01 PM   #310
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Have you figured out yet, Este, that hospital lab reports of results ordered by physicians treating patients is not directly comparable to tests on specimens systematically sampled by sentinel providers?

Are you satisfied RSV deaths are recognized and are not being ignored as a proportion of the P&I deaths?

I think those objections have been addressed.


You still object to this:
Quote:
CDC estimates of annual influenza-associated deaths in the United States are made using well-established scientific methods that have been reviewed by scientists outside of CDC.
Your basis is a couple of scientists don't agree, is that correct?


Quote:
Death certificate data and weekly influenza virus surveillance information was used to estimate how many flu-related deaths occurred among people whose underlying cause of death was listed as respiratory or circulatory disease on their death certificate.
I don't see that Doshi makes a good case against the way flu viral culture surveillance is used to estimate flu burden.


Doshi said:
Quote:
Thus the much publicised figure of 36 000 is not an estimate of yearly flu deaths, as widely reported in both the lay and scientific press, but an estimate—generated by a model—of flu-associated death.
I fail to feel the outrage there.


He makes this assertion:
Quote:
Yet this stance is incompatible with the CDC assertion that the flu kills 36 000 people a year—a misrepresentation that is yet to be publicly corrected.
That is inconsistent with the CDC's actual position:
Quote:
The 36,000 estimate was presented in a 2003 study by CDC scientists ... CDC believes that the range of deaths over the past 31 years (~3,000 to ~49,000) is a more accurate representation of the unpredictability and variability of flu-associated deaths.
Could just be the timing of his comments, but regardless, I don't find the complaint of the CDC simplifying messages for the public to be all that outrageous either.


Doshi complains:
Quote:
CDC is already working in manufacturers' interest by conducting campaigns to increase flu vaccination.
He suggests the CDC is acting as the vaccine manufacturers' puppet.

I don't buy it. The Flu Protection Act of 2005 and the CDC's deals with manufacturers followed a couple years of severe vaccine shortage. People who wanted vaccine could not get it. The vaccine market's unpredictable demand had resulted in manufacturers dropping out of the field. In one year, with only 2 flu vaccine manufacturers left, half the supply was lost when all the vaccine from one manufacturer was lost due to contamination.

It was the CDC that felt this was a bad situation, it wasn't manufacturers conning the CDC to promote their products.

There is undoubtedly a political influence by very powerful Big Pharma lobbies on the US government, one need merely look at how the recent Medicare drug coverage doesn't allow the US to negotiate prices. People should be outraged about that.

And Goldacre's findings definitely needs more attention. People should be outraged about that.

But to paint all the CDC researchers and public health providers as incompetent, being duped, and/or in on the game, I don't see the evidence anywhere here that is the case. That's the typical anti-vaxer CT and it is not based on facts.

_________________________________________________


Now, certainly vaccine effectiveness is an issue and it's taken a while for the CDC to address this problem and the problem of missing negative results in the research literature (Goldacre's documented premise). To suggest the CDC is ignoring this problem is unfounded.

It remains to be seen if the higher dose vaccine will have a better result. I've not yet seen what percentage of the elderly received the higher dose vaccine this flu season. If the proportion was very high the results are not promising.


Regardless, there are still a couple of data bases that suggest universal flu vaccine recommendations do have a significant impact on influenza morbidity and mortality.

The experience of Ontario compared to other Canadian provinces mentioned in this thread, and I also found that the years Japan made flu vaccine a universal recommendation for school children, the country experienced a decrease in overall mortality during flu season that went up again when the program was stopped.


The Japanese Experience with Vaccinating Schoolchildren against Influenza
Quote:
Japan, however, once based its policy for the control of influenza on the vaccination of schoolchildren. From 1962 to 1987, most Japanese schoolchildren were vaccinated against influenza. For more than a decade, vaccination was mandatory, but the laws were relaxed in 1987 and repealed in 1994; subsequently, vaccination rates dropped to low levels....

METHODS
We analyzed the monthly rates of death from all causes and death attributed to pneumonia and influenza, as well as census data and statistics on the rates of vaccination for both Japan and the United States from 1949 through 1998. For each winter, we estimated the number of deaths per month in excess of a base-line level, defined as the average death rate in November.
...
RESULTS
The excess mortality from pneumonia and influenza and that from all causes were highly correlated in each country. In the United States, these rates were nearly constant over time. With the initiation of the vaccination program for schoolchildren in Japan, excess mortality rates dropped from values three to four times those in the United States to values similar to those in the United States. The vaccination of Japanese children prevented about 37,000 to 49,000 deaths per year, or about 1 death for every 420 children vaccinated. As the vaccination of schoolchildren was discontinued, the excess mortality rates in Japan increased.
Economic Appraisal of Ontario's Universal Influenza Immunization Program: A Cost-Utility Analysis
Quote:
the introduction of the UIIP reduced the number of influenza cases by nearly two-thirds and reduced deaths from influenza by more than a quarter compared with what would have been expected had the province continued to offer a TIIP, an overall saving of 1,134 QALYs. Furthermore, the reduction in influenza cases halved influenza-related health care costs, mainly because of reductions in hospitalization.
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Old 27th February 2013, 12:06 PM   #311
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Originally Posted by Estellea View Post
....
As for Doshi and Jefferson's "Big Pharma CT beliefs", how do you reconcile the fact that the CDC has finally acquiesced that flu vaccines are not efficacious in the elderly in spite of a good antigenic match and Jefferson's Cochrane review with your own confirmation bias? ...
Este
Considering the time it took to develop the high dose vaccine for the elderly, and the fact that years ago the CDC began looking at vaccinating school kids as the approach to protecting the elderly, I'd say your definition of "finally acquiesced" is lacking a factual basis.
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Old 27th February 2013, 02:25 PM   #312
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Originally Posted by Skeptic Ginger View Post
Have you figured out yet, Este, that hospital lab reports of results ordered by physicians treating patients is not directly comparable to tests on specimens systematically sampled by sentinel providers?

Are you satisfied RSV deaths are recognized and are not being ignored as a proportion of the P&I deaths?

I think those objections have been addressed.
How? With you going off the rails about random collections? What part of samples reported from the ILI network and NREVSS/WHO sentinel sites all used to tabulate flu burden are you having difficulty with?

Quote:
You still object to this:Your basis is a couple of scientists don't agree, is that correct?
No, that's not correct, it's the discrepancies between what the Thompson et al. study reports as annual flu mortality estimates, what the mortality statistics say, how the model was drafted and why. Since you are so confident in this model; you are clearly more knowledgeable than I, whereas I'm not a stats expert, have seen problems and would like some answers myself, perhaps you would be a dear and explain, for instance, why this model? Why not the previous Serfling model or a generalised linear regression model, something that measures the number of deaths for a specific pathogen that is proportional to the weekly viral lab confirmations instead of something multiplicative? Why indirect measurements when we have the infrastructure for direct measurements?

I'm sure you can clarify these few points for me right?

Quote:
I don't see that Doshi makes a good case against the way flu viral culture surveillance is used to estimate flu burden.
More argument from assertion. Given the historical data, the number of tests actually used to confirm flu-relatedness, I'd say he's on pretty solid footing here. But you could always provide some actual evidence to the contrary.

Quote:
Doshi said:I fail to feel the outrage there.
Faux ennui is hardly appropriate for an inflated or at the very least, un-evidenced flu mortality estimate used for years to justfy universal flu vaccination. But not unexpected given your devotion to your own grandiosity and rigidity.

Quote:
He makes this assertion:
That is inconsistent with the CDC's actual position: Could just be the timing of his comments, but regardless, I don't find the complaint of the CDC simplifying messages for the public to be all that outrageous either.
Considering his criticism took place before the CDC changed their estimate, timing is probably viable explanation as well as being the impetus for the CDC changing their estimate statement. Simplifying messages to the point that they convey the wrong idea for public consumption is still wrong. Even the current range is a bit misleading as the upper range is still questionable or at best, an infrequent occurance such that the mode or even median could be reported as well.

Quote:
Doshi complains:He suggests the CDC is acting as the vaccine manufacturers' puppet.

I don't buy it. The Flu Protection Act of 2005 and the CDC's deals with manufacturers followed a couple years of severe vaccine shortage. People who wanted vaccine could not get it. The vaccine market's unpredictable demand had resulted in manufacturers dropping out of the field. In one year, with only 2 flu vaccine manufacturers left, half the supply was lost when all the vaccine from one manufacturer was lost due to contamination.

It was the CDC that felt this was a bad situation, it wasn't manufacturers conning the CDC to promote their products.
I haven't seen a smoking gun but it's provocative and while I don't promote such an idea; I reserve the right to keep an open mind about it. As I see it now, the CDC has propagated demand to keep influenza vaccine manufacturers making vaccines; this is the basis for vaccine policy given the lack of evidence to support vaccination of certain age and risk groups. I take exception to that since it has given many a false sense of security and probably hindered more efficacious vaccines coming to the market.
Quote:
There is undoubtedly a political influence by very powerful Big Pharma lobbies on the US government, one need merely look at how the recent Medicare drug coverage doesn't allow the US to negotiate prices. People should be outraged about that.
Who says they aren't? So are you saying that no one look at the man behind the curtain over there because their outrage is better placed over here? What kind of stupid argument is that?

Quote:
And Goldacre's findings definitely needs more attention. People should be outraged about that.
Why because he doesn't attack vaccines? You haven't even read his book; I'm sure that there are many drugs that you swear by that he criticises, let's see how embracing you are of his evidence. But again, not relevant to this discussion.

Quote:
But to paint all the CDC researchers and public health providers as incompetent, being duped, and/or in on the game, I don't see the evidence anywhere here that is the case. That's the typical anti-vaxer CT and it is not based on facts.
There is plenty of evidence by Osterholm et al. and Jefferson et al. that does not put some public health decisions in a good light which you still refuse to accept and simply wave it away as "CT". It doesn't have to be all or nothing you know and simply dismissing anything untoward about the CDC as "anti-vaxxer CT" is a testament to your willful blindness.

_________________________________________________

Quote:
Now, certainly vaccine effectiveness is an issue and it's taken a while for the CDC to address this problem and the problem of missing negative results in the research literature (Goldacre's documented premise). To suggest the CDC is ignoring this problem is unfounded.
A while? It's been decades that the CDC has ignored the paucity and low-quality of the data regarding vaccine effectiveness in risk groups, particularly the elderly in spite of them recommending vaccination to them. And they are still saying to get the vaccine, it doesn't work in most for your group, but get it anyway, it's better than nothing. That is a grave disservice to our seniors and other high-risk groups when they should be promoting other mechanisms to prevent flu such as social-distancing, isolation, masks and hand-washing.
The Fluzone High-Dose page makes a passing remark about better theoretical protection but not proven although still says this:
Quote:
Does CDC recommend one vaccine above another for people 65 and older?

CDC and the Advisory Committee on Immunization Practices (ACIP) recommends flu vaccination as the first and most important step in protecting against the flu, however, neither CDC nor ACIP is expressing a preference of one vaccine over another at this time.
Given all that we know about flu vaccine effectiveness in >65s, how do you defend this statement?

Quote:
It remains to be seen if the higher dose vaccine will have a better result. I've not yet seen what percentage of the elderly received the higher dose vaccine this flu season. If the proportion was very high the results are not promising.
Yes, see above and tell me why public health organisations and healthcare practitioners aren't promoting other flu-prevention mechanisms as an adjunct to vaccination which is experimental at best and isn't effective at worst. And yet you still haven't answered my question of how you reconcile the CDC's admission that influenza vaccines are not efficacious in seniors, the Jefferson Cochrane Review that stated the same years ago and your claim that he is wrong and the "evidence is mounting against him".

Quote:
Regardless, there are still a couple of data bases that suggest universal flu vaccine recommendations do have a significant impact on influenza morbidity and mortality.

The experience of Ontario compared to other Canadian provinces mentioned in this thread, and I also found that the years Japan made flu vaccine a universal recommendation for school children, the country experienced a decrease in overall mortality during flu season that went up again when the program was stopped.


The Japanese Experience with Vaccinating Schoolchildren against Influenza

Economic Appraisal of Ontario's Universal Influenza Immunization Program: A Cost-Utility Analysis
The Ontario study was not all that as I explained but the observation from Japan may be real however it remains to be seen in practise in the U.S. in spite of the claim that studies into this were underway at the time of that NEJM study. They were also using an incorrect vaccine efficacy of 90% to construct their estimate for the number of persons needed to vaccinate for a herd effect. Now given your die-hard defence of CDC policy, I have to ask why this method wasn't tested but rather pour wasted resources into vaccinating the elderly for which no sound vaccine effectiveness data existed? The Japanese observation was from the 1990s so shouldn't this have registered with the powers that be?

Este
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Old 27th February 2013, 02:39 PM   #313
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The CDC will hold off on recommending the high dose vaccine until they see the data.

In addition, they are very reluctant to support any single brand of vaccine. There has to be overwhelming evidence before the CDC will allow its backing of one product over another. I'm not sure I've ever seen them do it.
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Old 27th February 2013, 03:39 PM   #314
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Originally Posted by Professor Yaffle View Post
In the UK, the pneumococcal vaccine (PCV) (as well as vaccines for some other illnesses that can cause pneumonia) is part of the childhood immunisation schedule. Elderly people and those is high risk groups are also offered this, or a similar pneumococcal vaccine (PPV).

http://www.nhs.uk/Conditions/vaccina...ccination.aspx
The pneumonia vaccine for older people (PPV, pneumococcal polysaccharide vaccine) doesn't really work:

http://www.columbiamedicine2.org/sit...%20Vaccine.pdf

(That's a vaccine that's probably on its way out)

The other vax (PCV, pneumococcal conjugate vaccine) is REALLY REALLY effective against vaccine serotypes of s pneumo, (streptococcus pneumoniae) but causes an increase of non-vaccine serotypes, and creates a need for what appears to be a neverending list of new vaccines. (It's called "serotype replacement" or "replacement disease"...first the vax against 7 s pneumo serotypes created the need for the vax against 13 serotypes...and now an even newer one will be needed for more emerging serotypes. To make matters worse, it seems more likely than not that knocking out all that s pneumo opens up a door for more staph to move in, and they think the "super staph" (which can also cause pneumonia) might have been partially given "room" to go epidemic by use of those super effective [pneumococcal conjugate vaccines, aka, PCV] s pneumo vaccines.
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Old 27th February 2013, 04:26 PM   #315
Skeptic Ginger
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Originally Posted by kellyb View Post
The pneumonia vaccine for older people (PPV, pneumococcal polysaccharide vaccine) doesn't really work:

http://www.columbiamedicine2.org/sit...%20Vaccine.pdf

(That's a vaccine that's probably on its way out)
From your own link:
Quote:
These findings support the effectiveness of the pneumococcal polysaccharide vaccine for the prevention of bacteremia, but they suggest that alternative strategies are needed to prevent nonbacteremic pneumonia, which is a more common manifestation of pneumococcal infection in elderly persons.
No harm, some good.



Originally Posted by kellyb View Post
The other vax (PCV, pneumococcal conjugate vaccine) is REALLY REALLY effective against vaccine serotypes of s pneumo, (streptococcus pneumoniae) but causes an increase of non-vaccine serotypes, and creates a need for what appears to be a neverending list of new vaccines. (It's called "serotype replacement" or "replacement disease"...first the vax against 7 s pneumo serotypes created the need for the vax against 13 serotypes...and now an even newer one will be needed for more emerging serotypes. To make matters worse, it seems more likely than not that knocking out all that s pneumo opens up a door for more staph to move in, and they think the "super staph" (which can also cause pneumonia) might have been partially given "room" to go epidemic by use of those super effective [pneumococcal conjugate vaccines, aka, PCV] s pneumo vaccines.
More anti-vaxer distortions. After the initial 7-valent vaccine, other strains emerged. Increasing the vaccine coverage is hardly a never ending, no benefit pursuit.

Invasive pneumococcal disease in children 5 years after conjugate vaccine introduction--eight states, 1998-2005.
Quote:
Results of that analysis indicated that in 2005, overall IPD rates among children aged <5 years were 77% lower, and an estimated 13,000 fewer cases of IPD occurred, compared with the years preceding vaccine introduction (1998-1999). Although IPD caused by PCV7 serotypes declined through 2005, overall IPD rates leveled off beginning in 2002, primarily because of increases in the incidence of IPD caused by non-PCV7 serotype 19A. Given these trends, use of expanded-valency conjugate vaccines might further reduce IPD incidence. Continued surveillance is needed to guide development of future formulations of conjugate vaccines and to monitor the effects of continued vaccine use.
Declined then leveled off, not declined and returned to pre-vaccine levels.

You should start a new thread or dredge up an old one. This thread is complex enough as it is. You are making an unsupported claim that pneumococcal disease in kids is just being replaced with staph infections. The worldwide pandemic of the USA300 strain of MRSA is related to a mutation causing the Pantone Valentine Leukocidin enzyme emergence. I'm guessing you are mixing more than a few things up here.
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Old 27th February 2013, 05:22 PM   #316
Estellea
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Originally Posted by Skeptic Ginger View Post
The CDC will hold off on recommending the high dose vaccine until they see the data.

In addition, they are very reluctant to support any single brand of vaccine. There has to be overwhelming evidence before the CDC will allow its backing of one product over another. I'm not sure I've ever seen them do it.
Okay, let's try this again with (apparently-needed) emphasis:
Quote:
Does CDC recommend one vaccine above another for people 65 and older?

CDC and the Advisory Committee on Immunization Practices (ACIP) recommends flu vaccination as the first and most important step in protecting against the flu, however, neither CDC nor ACIP is expressing a preference of one vaccine over another at this time.
Clear now? How do you defend this statement in the face of the mostly absent effectiveness of flu vaccines in seniors? And now that you mention it, if you have a vaccine that has been specifically formulated for seniors, why not recommend it?

Este
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Old 27th February 2013, 05:26 PM   #317
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Originally Posted by Estellea View Post
Okay, let's try this again with (apparently-needed) emphasis:

Clear now? How do you defend this statement in the face of the mostly absent effectiveness of flu vaccines in seniors? And now that you mention it, if you have a vaccine that has been specifically formulated for seniors, why not recommend it?

Este
What is it about my answer didn't you understand?
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Old 27th February 2013, 06:17 PM   #318
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Originally Posted by Skeptic Ginger View Post
What is it about my answer didn't you understand?
Um it wasn't pertinent to the question I was asking? This was my initial question:
"How do you defend this statement in the face of the mostly absent effectiveness of flu vaccines in seniors?" I then asked you, "And now that you mention it, if you have a vaccine that has been specifically formulated for seniors, why not recommend it?" in light of your misunderstanding of what I was asking to begin with.

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Old 27th February 2013, 06:31 PM   #319
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Originally Posted by Skeptic Ginger View Post
From your own link:No harm, some good.



More anti-vaxer distortions. After the initial 7-valent vaccine, other strains emerged. Increasing the vaccine coverage is hardly a never ending, no benefit pursuit.

Invasive pneumococcal disease in children 5 years after conjugate vaccine introduction--eight states, 1998-2005.Declined then leveled off, not declined and returned to pre-vaccine levels.

You should start a new thread or dredge up an old one. This thread is complex enough as it is. You are making an unsupported claim that pneumococcal disease in kids is just being replaced with staph infections. The worldwide pandemic of the USA300 strain of MRSA is related to a mutation causing the Pantone Valentine Leukocidin enzyme emergence. I'm guessing you are mixing more than a few things up here.
I'm not interested in going down this road either, particularly given that you refuse to follow through with specific criticism of the Cochrane Reviews in spite of making hay over them. However, you are on very shaky ground, yet again and I strongly suggest you do some research before inserting your foot into your mouth, yet again.

Este
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Old 2nd March 2013, 02:39 PM   #320
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Hmm. Well there's this (which I will admit up front to not having read in detail):

"Mar 1, 2013 (CIDRAP News) – Experts are puzzled by a new study in which influenza vaccination seemed to provide little or no protection against flu in the 2010-11 season—and in which the only participants who seemed to benefit from the vaccine were those who hadn't been vaccinated the season before."

http://www.cidrap.umn.edu/cidrap/con...13vestudy.html

Troubling. The first thing that pops into my head is "original antigenic sin" -- a notion I seem to recall having argued with some vigor against; at least against the idea of it being a very common occurrance. (I've never known Kelly to be the sort of person to gloat, but it looks as though she may have earned that right in this case, whether she choses to use it or not.)

Seems like the more I learn about flu, the less I know for sure.
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