Influenza Vaccine 2008: Fill & Download for Free

'Is the human body not capable of dealing with the flu without any preventive medication?'.Flu (influenza) is a seasonal disease, typically prevalent in winter in the US. Many among the unvaccinated contract and survive the flu each year suggesting many humans are capable of dealing with it without preventive medicine. However, flu strains tend to be different from year to year and strains circulating one year can be more deadly than those in other years.The 1918 flu pandemic - Wikipedia is estimated to have killed at least 50 million.While not as deadly, subsequent flu pandemics, Influenza pandemic - Wikipedia, such as those in 1957, 1968 and 2009 also killed many.Even today, according to the WHO, seasonal flu leads to an estimated 3 to 5 million global cases of severe illness with ~250000 to 500000 deaths each year (1).Typically, flu lethality disproportionately affects the very young, the very old and the already ill, the 1918 and 2009 pandemics being exceptions in disproportionately felling those between 20 and 40 years of age.Already, apparently the major flu strain circulating in 2017, the influenza A strain H3N2, has led to the headline-grabbing death of an unvaccinated 20 year old mom of two in Arizona (2).Further, seasonal flu is consistently a bigger problem for the older in the US, emerging as the major cause of death among those aged 65 or older, often not directly but as a result of pneumonia from secondary bacterial infections, speculatively an outcome of weakened immune system (3, 4).'Why are flu and flu shots such a big deal in the US? '.Different countries recommend vaccines for different diseases based on their region-specific disease profiles and economic capability. In the US, vaccine recommendations are made by the Advisory Committee on Immunization Practices - Wikipedia (ACIP) which publishes annual flu vaccine recommendations.Flu vaccines were licensed in the US in 1968 and only began to be included in the pediatric schedule (specifically for those aged 6 to 24 months) in 2004 (5). Starting in 2000, ACIP began incrementally increasing its annual vaccination recommendations to include ~84% of the US population by 2009. In 2010, the ACIP expanded its influenza vaccine recommendation further to all US residents >6 months of age (6), the rationale being the 2009 pandemic H1N1 flu outbreak, where those with greater risk for complications or more severe infections were found to beAdults <50 years of age (7).Those with obesity (8, 9).Specific ethnicities (10, 11).Postpartum women (12, 13, 14, 15).Bigger Picture Look on Current Flu Shots: A Sub-optimal Solution to a Real ProblemPush for flu vaccines is predicated on two notions, that theyEngender milder symptoms compared to those in the unvaccinated.Reduce risk of spread to vulnerable groups (the very young, the elderly or already ill), a consequence of herd immunity.Problem with current flu vaccines is a hit-or-miss situation since their efficacy varies greatly from year to year depending on how well the strains used in the vaccine match those dominating the circulation in a given year (see below from 16, emphasis mine).'The cornerstone of influenza prevention and epidemic control is strain-specific vaccination. Since influenza viruses are subject to continual antigenic changes (“antigenic drift”), vaccine updates are recommended by the WHO each February for the Northern Hemisphere and each September for the Southern Hemisphere. This guidance relies on global viral surveillance data from the previous 5 to 8 months and occurs 6 to 9 months before vaccine deployment. In addition, there are always several closely related strains circulating; therefore, experts must combine antigenic and genetic characterization and modeling to predict which strains are likely to predominate in the coming season.'See below from 17, emphasis mine.'Seasonal influenza outbreaks predictably occur each year and cause an estimated 250,000 to 500,000 annual deaths worldwide (WHO, 2008). Pandemics are highly unpredictable, but pose an even greater threat when they occur. There have been 4 distinct pandemics in the 20th and into the 21st century: 1918, 1957, 1968, and 2009. The worst of these, the 1918 H1N1 influenza pandemic, resulted in 50–100 million deaths globally (WHO, 2014). Despite this substantial disease burden, licensed vaccines provide suboptimal protection against seasonal influenza (typically ranging from 10% to 60%), need to be updated each year, and provide little or no protection against new pandemic influenza strains (CDC, 2017).A universal flu vaccine that could protect against most seasonal flu strains would be a far better option. However, substantial hurdles range from vaccine design to what represents protective immunity and how to assess it to how to produce such a vaccine.'Obviously, a universal flu vaccine would be a better solution. Hurdles in the way include figuring out optimal vaccine design, specifically which antigens to include, research on and agreement about the types of immune response that best reflect protection, i.e., correlates of protection, and appropriate methods to produce vaccine such that it retains capacity to mimic as much as possible ability to drive infection-like immunity that is robust and long-standing while still being safe. Greater public support, more funding for flu research and development, better ideas and more creativity, all these are needed to improve this sub-optimal status quo.Bibliography1. World Health Organization. "Barriers of influenza vaccination intention and behavior: a systematic review of influenza vaccine hesitancy 2005–2016." (2016). http://apps.who.int/iris/bitstream/10665/251671/1/WHO-HIS-TTi-GAP-16.2-eng.pdf2. A mother got the flu from her children — and was dead two days later3. Thompson, William W., et al. "Mortality associated with influenza and respiratory syncytial virus in the United States." Jama 289.2 (2003): 179-186. https://pdfs.semanticscholar.org/6fc2/7fbd827b21dfd54e20144678fd4262f1afdb.pdf4. Matias, Gonçalo, et al. "Estimates of hospitalization attributable to influenza and RSV in the US during 1997–2009, by age and risk status." BMC public health 17.1 (2017): 271. https://pdfs.semanticscholar.org/b299/818f0a5225968e4fa118e39e3824994cff14.pdf5. Harper, Scott A., et al. "Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP)." Morbidity and Mortality Weekly Report: Recommendations and Reports 54.8 (2005): 1-41. https://www.researchgate.net/profile/Carolyn_Bridges2/publication/10753336_Bridges_CB_Harper_SA_Fukuda_K_et_al_Prevention_and_control_of_influenza_Recommendations_of_the_Advisory_Committee_on_Immunization_Practices_ACIP_MMWR_Recomm_Rep_52_1-34_quiz_CE1-4/links/00b7d529dd54d69f72000000.pdf6. Grohskopf, Lisa A., et al. "Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2017–18 influenza season." American Journal of Transplantation 17.11 (2017): 2970-2982. http://onlinelibrary.wiley.com/doi/10.1111/ajt.14511/epdf7. Fiore, Anthony E., et al. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. Department of Health and Human Services, Centers for Disease Control and Prevention, 2010. https://www.cdc.gov/mmwr/pdf/rr/rr5908.pdf8. Louie, Janice K., et al. "A novel risk factor for a novel virus: obesity and 2009 pandemic influenza A (H1N1)." Clinical Infectious Diseases 52.3 (2011): 301-312. https://pdfs.semanticscholar.org/a8b2/c28e98139dc24d160f54d5ced3e0427e0a26.pdf9. Morgan, Oliver W., et al. "Morbid obesity as a risk factor for hospitalization and death due to 2009 pandemic influenza A (H1N1) disease." PloS one 5.3 (2010): e9694. http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0009694&type=printable10. Castrodale, L., et al. "Deaths related to 2009 pandemic influenza A (H1N1) among American Indian/Alaska Natives-12 states, 2009." Morbidity and Mortality Weekly Report 58.48 (2009): 1341-1344. Deaths Related to 2009 Pandemic Influenza A (H1N1) Among American Indian/Alaska Natives --- 12 States, 200911. Wenger, Jay D., et al. "2009 Pandemic influenza A H1N1 in Alaska: temporal and geographic characteristics of spread and increased risk of hospitalization among Alaska Native and Asian/Pacific Islander people." Clinical Infectious Diseases 52.suppl_1 (2011): S189-S197. https://www.researchgate.net/profile/John_Redd2/publication/50264786_2009_Pandemic_Influenza_A_H1N1_in_Alaska_Temporal_and_Geographic_Characteristics_of_Spread_and_Increased_Risk_of_Hospitalization_among_Alaska_Native_and_AsianPacific_Islander_People/links/5460d1390cf2c1a63bff71ef.pdf12. Siston, Alicia M., et al. "Pandemic 2009 influenza A (H1N1) virus illness among pregnant women in the United States." Jama 303.15 (2010): 1517-1525. https://www.researchgate.net/profile/Katherine_Seib/publication/43226995_Pandemic_2009_Influenza_AH1N1_Virus_Illness_Among_Pregnant_Women_in_the_United_States/links/004635367ec7ea16ba000000/Pandemic-2009-Influenza-AH1N1-Virus-Illness-Among-Pregnant-Women-in-the-United-States.pdf13. Creanga, Andreea A., et al. "Severity of 2009 pandemic influenza A (H1N1) virus infection in pregnant women." Obstetrics & Gynecology 115.4 (2010): 717-726.14. Jamieson, Denise J., et al. "H1N1 2009 influenza virus infection during pregnancy in the USA." The Lancet 374.9688 (2009): 451-458. http://med-fom-apt.sites.olt.ubc.ca/files/2012/05/H1N1-and-Pregnancy.pdf15. Louie, Janice K., et al. "Severe 2009 H1N1 influenza in pregnant and postpartum women in California." New England Journal of Medicine 362.1 (2010): 27-35. http://www.nejm.org/doi/pdf/10.1056/NEJMoa091044416. Paules, Catharine I., et al. "Chasing Seasonal Influenza—The Need for a Universal Influenza Vaccine." New England Journal of Medicine (2017). http://www.nejm.org/doi/pdf/10.1056/NEJMp171491617. Paules, Catharine I., et al. "The Pathway to a Universal Influenza Vaccine." Immunity 47.4 (2017): 599-603.Thanks for the R2A, Santosh Kumar.

Guide to the Answer:A. History of VaccinationB. Major Arguments Against VaccinationThe history of vaccination is long - very long. I think in order to understand our current resistance to vaccination you need to understand the history a little. Throughout the story you will see a pattern -“We don’t like what we don’t understand, in fact it scares us, and this monster is mysterious at least!”Historians noted that people began observing the protective effect of acquiring some diseases, such as smallpox as early as 430 BC.[1] Records from the 10th century indicate Chinese physicians were inoculating through a process called “variolation” - deliberate infection with disease by blowing scabs up a healthy person’s nose. Variolation worked, too - cutting mortality from around 30% down to 1–2%.[2]Why would it take so many centuries? There were several problems. First, the early inoculation attempts worked — sort of. Often the person would get a lesser form of the disease. Sometimes they wouldn't. Sometimes they’d contract another disease. Because the physicians had no clue about other blood-borne diseases, sterile technique, secondary infections and the like, they often caused unexpected problems that were rather difficult to understand.Above everything else — no one really understood why people got sick in the first place, much less why this method of making a person sick — just less sick — worked. Germ theory of disease was proposed in 1546, and improved in 1762 — but largely ignored in favor the more plausible miasma (bad air) theory, which went back to antiquity (note to scientists — beware of “settled science”!) So the physicians by and large believed that smallpox was caused by “bad air”, and for whatever reason, exposing people to the lesions and giving them the disease this way protected them against the disease contracted through the “bad air” — particularly if a worse case of “bad air” came along.The physicians were pragmatic — they observed it worked, so they wanted to do it, but let’s be real here, the treatment is a bit gross. A lot gross. The physicians were cutting open scabs from the following types of lesions:People were terrified of this disease, and rightfully so. It killed between 30% to 100% of the people who got it, depending on the strain. Many people who survived were scarred for life. They might go blind, or become completely crippled from the disease attacking their bones and joints.Physicians were asking people to let them take fluid or powder from those pustules, and blow it up their nose or inject it right into them. Think about how frightening that must have been! They didn't even want to be near someone with the disease, or near someone who had been near a person with it because they all knew it was contagious. This was a terrible invasion of privacy.So people did what people always do — they invented a million reasons the physician should NOT do this terrifying thing to them.In 1721 a tremendous smallpox epidemic broke out in Boston. The Rev. Cotton Mather initiated a highly controversial inoculation program. Yes, that Cotton Mather, of the Salem Witch Trials — he wasn’t all bad.mezzotint portrait of Cotton Mather (Feb. 12, 1663 - Feb. 13, 1728), American Puritan clergyman.Peter Pelham, artist - http://www.columbia.edu/itc/law/witt/images/lect3/Cotton Mather was inspired by a slave named Onesimus, who told him about his inoculation in Africa, and by a letter published to the Royal Society of London in 1721 by Emanuale Timoni describing the procedure and its efficacy. He was backed by exactly one physician — Zabdiel Boylston. He faced opposition that was religious and scientific.Why do you fight God’s will? (doesn’t this sound familiar)There’s not enough evidence to use that method (not a bad science argument).Cotton Mather and Zabdiel Boylston decided to argue against the religious people with a fairly succinct message — this is no different than any other invasive medical procedure.And the scientific argument? Well — that meant collecting data. So they began inoculating people — not as many as they could have if they had had the support of the town’s physicians as a whole, but they managed to inoculate 287, and only 2% died, compared to nearly 15% of those in the city at large.[3] That largely put the matter to rest in the mind of the scientific community, and the practice was adopted to the great health benefit of the Boston community. (See graph below)The Fight Over Inoculation During the 1721 Boston Smallpox Epidemic - Science in the NewsNow, keep in mind, people still had no idea why this worked. Only that it did.Twenty years later, in 1774, a farmer in England named Benjamin Jetsay contracted cowpox. All the dairy farmers and milkmaids knew if you got cowpox, you could safely nurse people with smallpox and you wouldn't get the disease. Cowpox was much milder than any form of smallpox, so this was very good. Jetsay had heard about inoculating people with smallpox, and even though he wasn't a doctor, he decided to deliberately inoculate his wife and sons with cowpox.[4]It worked.It was another twenty years before Edward Jenner caught wind of this wonderful phenomenon, and decided to stake his career as a physician on it. In 1796, Jenner gave his first trial, inoculating a child with material he gathered from a milkmaid’s pustule. He continued his inoculations, and two years later published “An Inquiry into the Causes and Effects of the Variolae Vacciniae.”[5] The book was pretty much a hit — people read it — and debated it widely — but it wasn't really accepted by the scientific community immediately. Jenner had to do a lot of work to get this idea accepted. However, he was tireless, and vaccination spread through England, and ultimately to America as well.That’s not to say it didn't have people up in arms!James Gillray's The Cow-Pock—or—the Wonderful Effects of the New Inoculation!, Library of Congress, Prints & Photographs Division, LC-USZC4-3147As you can see from the image abov,e there were those who thought that cowpox inoculation might turn you into a cow. Does this really seem much different than modern-day fears?All this — and people still thought disease was transmitted by “bad air”. Although several physicians working with microscopes had described microorganisms and implicated them in the bubonic plague (black death), smallpox, measles, rabies, and others, their work by and large just wasn’t accepted by physicians or the public.This work was probably set back in no small part due to the understandable fear of Antonie van Leeuwenhoek[6], “the father of Microbiology”, who developed a unique method of grinding lenses in the 1650s that enabled him to create microscopes of spectacular resolution. Due to a lack of patent law protection, he guarded his secrets and took them to his grave, and similar caliber instruments weren't developed for almost 200 years. This set back microbiology by about the same amount.The Geographer - by Johannes Vermeer - historians believe painting is of Antonie van Leeuwenhoek[7]It wasn’t until 1854 when a physician named John Snow, working to stem a cholera outbreak, realized that the disease must be transmitted by an agent present in water [8]— and that it was coming from feces of infected individuals. He meticulously detailed the contamination of water used for drinking and cooking with waste from infected individuals in a number of cases. Only after removing a single pump he believed infected with cholera did the epidemic in London subside.After another outbreak, he argued strenuously for filtration of water. He was convinced that people’s poop was contaminating water, and in drinking water with poop from sick individuals, everyone was getting sick and dying. Unfortunately for the citizens of London, and the world elsewhere, his ideas were slow to catch on. Why?It was too disgusting to accept.[9]How slow? Well, in 1854 the Italian scientist Filippo Pacini published a full description of the virus[10] that caused cholera, and in subsequent years further described how to properly treat the disease as well as how the disease became so deadly[11]. Somewhat later, and independently of him, scientific literature not being quite so easy to share in the 19th century, Robert Koch published his work describing the same bacterium[12] (1884).Now you would think the matter of cholera settled, right? It is, after all, 2019. We've understood how to combat this disease now for over 150 years.WHO Cholera Kit inforgaphic. [13]From the infographic: “Researchers estimate there are as many as 4 million cases each year and up to 143,000 deaths annually (2017).”OK, but what does this have to do with worldwide anti-vaccination sentiment?A lot, I’m afraid. You see, the persistence of cholera is only one symptom of the anti-vaccination sentiment that’s been around since the beginning of vaccination. The first cholera vaccination was available in the 1880s.[14] People are still afraid to get vaccinated even when they know they run a high risk of contracting and dying from cholera, a disease that has mortality between 10–90%, and can kill within 2 hours[15].2 hours.Did I mention there are vaccines for this? Now you’d think people would be MORE afraid of cholera than of vaccines, but — no. In fact, they’re not even afraid enough of cholera to wash their hands or drink bottled water consistently.[16] People are weird like that.Throughout history, and worldwide, people invoke the same reasons over and over and over for why vaccination is bad, or at least just isn't right for them.[17][18][19] [20][21] [22] [23] [24]Moral/Religious FoundationInvulnerabilityCost/Benefit Ratio isn't worthwhile* (this is complex)Fear of Bad EffectsNone of these are irrational — per se — not even the moral/religious foundation argument.Moral/Religious FoundationThis argument hasn't changed much. There aren’t that many groups [25]that claim a religious exemption to vaccination, and those that do aren’t under significant expansion in numbers. You’ve got the Christian Scientists, and some members of the Dutch Reformed church. For major religions, that’s it.InvulnerabilityCalvin of Calvin and Hobbes - being selective about accepting realityPeople are very good at this — feeling invincible. Invulnerable. That’s why 15% of Americans don’t use seat belts[26] and 43% of drivers admit to texting and driving[27] (seriously, people STOP IT!). When it comes to vaccines, a fair number of people don’t believe they or their child will actually become ill, so they forgo vaccines. This is a major factor in why people routinely travel without proper vaccinations.Cost/Benefit Ratio isn’t worthwhile* (this is complex)Costs of vaccination vary widely. Many people receive free or low-cost vaccination for children — but the money cost isn't the only cost involved. There’s time spent traveling to and from the provider. This may be fairly trivial in much of the Western world, where vaccinations can be received at any grocery store pharmacy as well as community clinic or hospital, but in developing nations it can present a huge roadblock. A parent may not want to deal with a child being feverish or cranky after vaccination after a tough night on a previous course. They may perceive vaccines as not being effective enough to justify the cost or inconvenience (this is especially true with influenza vaccines). A lot goes into the decision to actually get up and go get a vaccination — and people acting in rational self-interest don’t always weigh the factors the way those invested in public health would hope they should.Fear of Bad EffectsBy far and away, the current anti-vaccine sentiment roared to a new momentum with the 1998 study led by Andrew Wakefield that seemed to link autism to the combined measles mumps & rubella (MMR) vaccine.[28]Andrew Wakefield, Certified FraudThat study was a disaster from the moment of publication — and honestly, it wreaked havoc in far more than just vaccine science. In that same paper, now retracted, which cost Wakefield his medical license, [29]Wakefield et al. proposed the now terribly popular “leaky gut” theory that you can find all over the place — that GI disturbances from food cause a “leaky gut” which in turn leads to “bad blood” and every ailment known to mankind. All of it is modern quackery nonsense, and all of it widely embraced by far more than just those afraid of vaccines.The study was a disaster — with a selected sample size of 12, no control, and terrible statistics, The Lancet never should have published it. Publish it they did, and the damage was done. His co-authors ultimately retracted the paper, but Wakefield went on a martyr tour, selling his “leaky gut” hypothesis. After that, as they say, the horse was out of the barn, and hysterics piled on.“Thiomersal!” became the new rallying cry. As with the MMR issue, there was little scientific evidence for that hypothesis, and a lot against it.[30][31]In fact, there is only one serious research group pursuing this theory at this time, and they self-refer to their own studies most of the time, a hallmark of quack science. Moreover, even though the use of the preservative was phased out[32] in most of Europe and the U.S. after 1999, autism rates continue to rise — making the correlation hypothesis very difficult to support.This is the oldest, and most intractable of the problems — yet seemingly the most simple. Unfortunately, it goes hand-in-hand with distrust of authority, so reinforcement by peer networks is playing a large role in the spread of anti-vaccination sentiment.Combating this movement will require a good deal of public health work[33] — but it also is a responsibility of every parent and citizen. Talk to your friends and neighbors. Encourage vaccination with positive, fact-based information. When you see them spreading misinformation, don’t be afraid to point it out — tactfully. (OK, I admit — this can be hard!). Ultimately vaccination protects both individuals and the population.It’s a wonderful time we live in, when so many awful diseases can be prevented. Now, if only we can get everyone to fully appreciate how lucky we are!Now go check to make sure your vaccines are up-to-date.And get your flu shot!Don’t forget — immunizations are for adults, too!Relaxed. Researched. Respectful. - War ElephantFootnotes[1] http://Gross, C. P., & Sepkowitz, K. A. (1998). The myth of the medical breakthrough: smallpox, vaccination, and Jenner reconsidered. International journal of infectious diseases, 3(1), 54-60.[2] Smallpox: Variolation[3] The Fight Over Inoculation During the 1721 Boston Smallpox Epidemic - Science in the News[4] http:// Nicolau Barquet and Pere Domingo. "Smallpox: The Triumph over the Most Terrible of the Ministers of Death". Annals of Internal Medicine. Retrieved 2006-10-26.[5] http://Jenner, E. (1800). An inquiry into the causes and effects of the variolae vaccinae, a disease discovered in some of the western counties of England, particularly Gloucestershire, and known by the name of the cow pox. author.[6] Antonie van Leeuwenhoek | Biography, Discoveries, & Facts[7] The Geographer by Johannes Vermeer: Geography in Fine Art[8] http://Snow, J. (1855). On the mode of communication of cholera. John Churchill.[9] http://Chapelle, Frank (2005) Wellsprings. New Brunswick, New Jersey: Rutgers University Press. ISBN 0-8135-3614-6. p. 82[10] http://Pacini, F. (1854). Osservazioni microscopiche e deduzioni patologiche sul cholera asiatico. tip. di F. Bencini.[11] Who first discovered cholera?[12] http://Koch, R. (1884). An address on cholera and its bacillus. British medical journal, 2(1236), 453.[13] World Health Organization[14] http://Barrett, A. D., & Stanberry, L. R. (2009). Vaccines for biodefense and emerging and neglected diseases. Academic Press.[15] Cholera - Symptoms and causes[16] http://KOZICKI, MARKUS, ROBERT STEFFEN, and MEINRAD SCHÄR. "‘Boil it Cook it, Peel it or Forget it’: Does this Rule Prevent Travellers ‘Diarrhoea?." International journal of epidemiology 14.1 (1985): 169-172.[17] The Four Main Reasons People Don't Vaccinate[18] http://Gordon, D., Waller, J., & Marlow, L. A. (2011). Attitudes to HPV vaccination among mothers in the British Jewish community: reasons for accepting or declining the vaccine. Vaccine, 29(43), 7350-7356.[19] http://Canning, H. S., Phillips, J., & Stephen Allsup, M. D. (2005). Health care worker beliefs about influenza vaccine and reasons for non‐vaccination–a cross‐sectional survey. Journal of clinical nursing, 14(8), 922-925.[20] http://Kee, S. Y., Lee, J. S., Cheong, H. J., Chun, B. C., Song, J. Y., Choi, W. S., ... & Kim, W. J. (2007). Influenza vaccine coverage rates and perceptions on vaccination in South Korea. Journal of Infection, 55(3), 273-281.[21] http://Singleton, J. A., Santibanez, T. A., & Wortley, P. M. (2005). Influenza and pneumococcal vaccination of adults aged≥ 65: racial/ethnic differences. American journal of preventive medicine, 29(5), 412-420.[22] http://Constantine, N. A., & Jerman, P. (2007). Acceptance of human papillomavirus vaccination among Californian parents of daughters: a representative statewide analysis. Journal of Adolescent Health, 40(2), 108-115.[23] http://Darden, P. M., Thompson, D. M., Roberts, J. R., Hale, J. J., Pope, C., Naifeh, M., & Jacobson, R. M. (2013). Reasons for not vaccinating adolescents: National Immunization Survey of Teens, 2008–2010. Pediatrics, peds-2012.[24] http://Francis, M. R., Nohynek, H., Larson, H., Balraj, V., Mohan, V. R., Kang, G., & Nuorti, J. P. (2018). Factors associated with routine childhood vaccine uptake and reasons for non-vaccination in India: 1998–2008. Vaccine, 36(44), 6559-6566.[25] http://Grabenstein, J. D. (2013). What the world's religions teach, applied to vaccines and immune globulins. Vaccine, 31(16), 2011-2023.[26] Policy Impact: Seat Belts[27] Facts & Statistics About Texting & Driving (Updated for 2018)[28] http://Wakefield, A. J., Murch, S. H., Anthony, A., Linnell, J., Casson, D. M., Malik, M., ... & Valentine, A. (1998). RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children.[29] Doctor behind vaccine-autism link loses license | TIME.com[30] http://Gadad, B. S., Li, W., Yazdani, U., Grady, S., Johnson, T., Hammond, J., ... & Ferrier, C. (2015). Administration of thimerosal-containing vaccines to infant rhesus macaques does not result in autism-like behavior or neuropathology. Proceedings of the National Academy of Sciences, 112(40), 12498-12503.[31] http://Uno, Y., Uchiyama, T., Kurosawa, M., Aleksic, B., & Ozaki, N. (2015). Early exposure to the combined measles–mumps–rubella vaccine and thimerosal-containing vaccines and risk of autism spectrum disorder. Vaccine, 33(21), 2511-2516.[32] Thiomersal - Wikipedia[33] The International Roadblocks To Achieving Global Vaccination

For this flu season, the CDC recommends against the live attenuated vaccine (intranasal) due to low efficacy against certain strains in recent years. This varies feom year to year and is a bit of a prediction on the part of the CDC. From their website:“In light of concerns regarding low effectiveness against influenza A(H1N1)pdm09 in the United States during the 2013–14 and 2015–16 seasons, for the 2016–17 season, ACIP makes the interim recommendation that live attenuated influenza vaccine (LAIV4) should not be used. Vaccine virus strains included in the 2016–17 U.S. trivalent influenza vaccines will be an A/California/7/2009 (H1N1)–like virus, an A/Hong Kong/4801/2014 (H3N2)–like virus, and a B/Brisbane/60/2008–like virus (Victoria lineage). Quadrivalent vaccines will include an additional influenza B virus strain, a B/Phuket/3073/2013–like virus (Yamagata lineage).”