Talk:Influenza vaccine/Archive 3

Orphaned references in Influenza vaccine
I check pages listed in Category:Pages with incorrect ref formatting to try to fix reference errors. One of the things I do is look for content for orphaned references in wikilinked articles. I have found content for some of Influenza vaccine's orphans, the problem is that I found more than one version. I can't determine which (if any) is correct for this article, so I am asking for a sentient editor to look it over and copy the correct ref content into this article.

Reference named "Potter": From Influenza pandemic:  From 1918 flu pandemic:  From Influenza:  

I apologize if any of the above are effectively identical; I am just a simple computer program, so I can't determine whether minor differences are significant or not. AnomieBOT ⚡ 19:44, 17 June 2013 (UTC)

Influenza vaccination reduces heart attacks significantly -- study
C Raina MacIntyre1,2, Anita E Heywood1, Pramesh Kovoor3, Iman Ridda1,2, Holly Seale1, Timothy Tan3,4, Zhanhai Gao1, Anthea L Katelaris5, Ho Wai Derrick Siu5, Vincent Lo5, Richard Lindley3, Dominic E Dwyer3,6

Ischaemic heart disease, influenza and influenza vaccination: a prospective case control study

http://heart.bmj.com/content/early/2013/08/06/heartjnl-2013-304320.full?g=widget_default

Open Access Full Text

Heart doi:10.1136/heartjnl-2013-304320

Original article

Ocdnctx 03:22, August 30, 2013‎ (UTC)


 * An interesting study. Although it is a primary study, and thus not normally allowed as a source per WP:MEDRS, the results are interesting:


 * "...However, influenza vaccination was significantly protective (OR 0.55, 95% CI 0.35 to 0.85), with a vaccine effectiveness of 45% (95% CI 15% to 65%)."


 * "Conclusions: Recent influenza infection was an unrecognised comorbidity in almost 10% of hospital patients. Influenza did not predict AMI, but vaccination was significantly protective but underused. The potential population health impact of influenza vaccination, particularly in the age group 50–64 years, who are at risk for AMI but not targeted for vaccination, should be further explored. Our data should inform vaccination policy and cardiologists should be aware of missed opportunities to vaccinate individuals with ischaemic heart disease against influenza."


 * "At the least, clinicians should be aware of influenza and infection as an underlying and poorly diagnosed precipitant or comorbidity in hospitalised patients and of the preventive benefit of influenza vaccine for patients at risk for AMI."


 * Brangifer (talk) 05:23, 30 August 2013 (UTC)


 * The results are impressive.
 * Where a groundbreaking single study like this does not contradict reviews, consensus statements, etc., it should not be over-emphasized. But if it is the only thing directly on point, and occurred after the latest reviews, and is consistent with and explains prior population studies like more heart attacks during flu season, it would not be required to be suppressed. https://en.wikipedia.org/wiki/Wikipedia:MEDRS#Avoid_over-emphasizing_single_studies.2C_particularly_in_vitro_or_animal_studies — Preceding unsigned comment added by Ocdnctx (talk • contribs)


 * I'm not sure it's true to state that we don't already have secondary sources touching on this. According to our article, per the WHO:  high-risk patients form who vaccinations are recommended include "patients with chronic heart diseases (congenital heart disease, chronic heart failure, ischaemic heart disease)".  Isn't this related to this study's findings?   16:35, 30 August 2013 (UTC)
 * I would definitely exclude this article as a source, because it is primary - we can just rely on good old policy and guideline. On top of that, it is only a case control study, and the correlation they found (correlation is not causation) is maybe interesting, but to know if it is is real, you would need a double blinded prospective study.  The danger of including this in an article is that people will take it as information relevant to their health.   This study is suggestive but its findings are not medical knowledge yet.  I find the last sentence pretty darn irresponsible.  (also, some folks would make a big deal out of the fact that several of the authors are paid consultant to pharma companies that make and sell vaccines and would have an interest in promoting the use of flu vaccines more widely.  I don't make such a big deal out of that, but it does make one take the conclusions with a grain of salt; not a pound, but a grain.  It does make it clear that pharma has an interest in this area, and they should indeed fund prospective trials if they want to market their vaccines as MI-protective, so that the medical community has clear data to consider.) Jytdog (talk) 04:19, 31 August 2013 (UTC)

Vaccine-induced disease enhancement has been described in connection with several viral vaccines
The user QTxVi4bEMRbrNqOorWBV recently removed https://en.wikipedia.org/w/index.php?title=Influenza_vaccine&diff=570969365&oldid=570968691 my addition: A phenomenon called vaccine-associated enhanced respiratory disease was first observed in 2009 in Canada and further studies could replicate findings which conclude that flu strain vaccines can raise risk of severe infection.
 * Further reading https://en.wikipedia.org/w/index.php?title=Influenza_vaccine&diff=570969365&oldid=570968691
 * The study states = "Vaccine-induced disease enhancement has been described in connection with several viral vaccines in animal models and in humans. [..] These findings should be considered                       during the evaluation of universal influenza vaccines". It is not clear what QTxVi4bEMRbrNqOorWBV  means with undo reason ="This is a misinterpretation of the source which is about adverse vaccine interactions when the strain isn't properly identified.)" If you have to make an improvement, please suggest one, otherwies ei see no reason why this journal article or the news article shouldn't be included. Prokaryotes (talk) 17:31, 31 August 2013 (UTC)
 * The cited study is about adverse interactions between certain antibodies that are activated by vaccination for the wrong strains. Universal vaccines have been considered bad ideas for a while because of problems like this, and this is just more evidence that careful adjustment of the yearly flu vaccine is prudent. jps (talk) 17:38, 31 August 2013 (UTC)
 * You are active across many different talk pages and it seems that your actions may be in abrogation of the standards of WP:FRINGE. I have started a discussion at WP:FTN about them. Please remand further discussion there as I believe these edits are interrelated. Thanks. jps (talk) 17:35, 31 August 2013 (UTC)

Vaccination of elderly
Part of the article states that for the elderly, flu vaccines cut the risk of death from influenza in half, and reduce the chance of hospitalization by more than a quarter. Another part states that in the elderly (aged over 65 years) the majority of published studies have found that vaccination is cost-effective. But a third part states "Evidence for protection in adults aged 65 years or older is lacking." Is there a current scientific consensus? — Preceding unsigned comment added by Rolf h nelson (talk • contribs) 00:41, 16 September 2013 (UTC)

A novel flu virus has appeared in China. It is salient that annual seasonal flu vaccination may provide some protection against novel flu viruses
Annual seasonal flu vaccination may provide some level of protection against novel flu viruses. A number of studies suggest that seasonal flu vaccine may offer cross-protection, both against the H5N1-type (avian influenza) H5N1 infection   and the 2009 flu pandemic (the H1N1 "swine flu.")    Vaccine protection can be long-lasting. Participants who received vaccination against the swine flu in 1976 still enjoyed benefits 33 years later, exhibiting a significantly enhanced immune response to the 2009 pandemic H1N1.
 * Cross-protection normally occurs when there are antigenic similarities between the strains; one might well expect that an earlier exposure to a strain of H1N1 could provide protection against a later strain, due to similarities in the antigens. As one article you cited mentions, the neuraminidase antibodies may provide some degree of cross protection against H5N1; if the N1 is similar to the N1 in a strain we have previously encountered (like an H1N1 strain) it is entirely possible that one could derive some degree of cross protection.  Hypothesizing that any historical vaccine could provide protection against a novel influenza like the H7N9, however, seems like a stretch, given that no approved vaccine has ever had either an H7 or an N9 antigen.  --Synaptophysin (talk) 13:42, 10 October 2013 (UTC)

Proposed deleting of paragraph describing seriously-flawed study
I am considering deleting the paragraph below on the grounds that the study overlooks the fact that in Canada healthcare (even an ER visit) is free, whereas in the United States, most people will at the very least face a co-pay for an ER visit, and quite possibly a bill for $300 to $1000 for an ER visit, even if they have insurance.
 * In 2006, the United States began recommending influenza vaccinations for preschoolers, but Canada did not follow suit until 2010, "thereby creating a natural experiment to evaluate the effect of the policy in the United States."[18] Studying the interim from the 2006 recommendation by the US and until 2010 when the Canadian recommendation to vaccinate preschoolers was initiated, a Canadian study found emergency room (ER) visits significantly lower for 2- to 4-year-olds in Boston than in Montreal (34% fewer ER trips). Vaccination of preschoolers may have reduced their likelihood of transmission of flu to older siblings and raised the chances that their parents would vaccinate older children as well, since there were also 18 percent fewer emergency room visits by 5- to 18-year-olds in Boston than Montreal during the study period.[19]

Comments in favor or opposed to deleting the paragraph would be appreciated. Tetsuo (talk) 00:50, 30 October 2013 (UTC)
 * Tetsuo you could be right for what little I know, but are you familiar with the policy of WP:OR? Rolf H Nelson (talk) 02:54, 31 October 2013 (UTC)
 * Per Rolf's comment, it's risky to offer our own personal evaluations of scientific papers; it tends to lead us into original research. We should wherever possible strive to rely on the evaluations presented in reliable secondary sources.
 * That said, your criticism seems to misunderstand the study methodology (which is another good reason not to rely too heavily on our own off-the-cuff personal reviews). The full study appears to be free online, and it's not too bad a read, as these things go: .  The authors looked at the proportion of pediatric ER visits that were for influenza-like illnesses at each hospital over the course of several flu seasons, and compared those proportions at the U.S. hospital and the Canadian hospital before versus after the 2006 U.S. recommendation. TenOfAllTrades(talk) 04:31, 31 October 2013 (UTC)

Thanks for that input. I didn't summarily delete the paragraph because I thought the paper might possibly have some merit, although it certainly wasn't evident to me from the summary in this Wikipedia article. I'm still shocked that a study based on such a flawed premise appeared in what is presumably a peer-reviewed journal. Let's see what comments others have. Tetsuo (talk) 06:08, 31 October 2013 (UTC)
 * Ah, I'm not sure what you're arguing is the "flawed premise" here, nor what the problem is you're seeing with the summary. The out-of-pocket cost of healthcare in the U.S. shouldn't affect the conclusion, given the way the analysis was performed, unless there was a significant jump in the cost of an ER visit in the U.S. that occurred in 2006 (and only in 2006) and which disproportionately affected the decisions (to come to the ER or not) of parents whose children had flu symptoms.  The study wasn't looking at the raw rate of kids showing up in the ER in each country, but at the ratio between the rates in the two countries.   TenOfAllTrades(talk) 06:39, 31 October 2013 (UTC)

The Wikipedia summary doesn't mention the words "proportion" or "ratio", so that is a major part of the problem. But I still don't consider the CMAJ article sufficiently conclusive to merit citation in Wikipedia. It is an interesting study, but I would term it "speculative". If I had reviewed that article, the sentence, "In 2003/2004 and 2007/2008, the influenza vaccine for each season and region exhibited a poor match with strains circulating in both regions" would certainly have raised a red flag. 2007/2008 is the period where the lines (ILI rate ratio for ER visits) in Fig. 2 begin to diverge, yet those were years when the vaccine wasn't well matched. That quoted sentence weakens or undermines the researchers' assertion that the divergence in the lines is due to vaccinations. Just eyeballing the graphs, it appears that after 2006 the ILI rate ratio went up in Montreal more than it went down in Boston. Also, the divergence appears greater in the 0-1 and 5-9 age groups. That makes me wonder if something else is going on with the data. I know the researchers mention that the 2-4 year-olds might spread the virus to older and younger siblings, but it still looks unconvincing.Tetsuo (talk) 07:19, 31 October 2013 (UTC)

"Vaccination recommendations" cleanup
"Vaccination recommendations" lacks references. I can add some, but I want to pin down the format first:

1. Should we break it down country-by-country, or keep the old format of one list that covers a bunch of the countries? Rolf H Nelson (talk) 03:13, 1 November 2013 (UTC)

2. Should the section continue to go into the level of detail of breaking out various conditions like "ischaemic heart disease", or should we summarize the content more briefly? Rolf H Nelson (talk) 03:13, 1 November 2013 (UTC)

Mild/common side effects?
Not even a section on the little and frequent symptoms of these shots? — Preceding unsigned comment added by 97.115.175.170 (talk) 00:26, 28 November 2013 (UTC)

Remove 2014 Vaccine Products
I don't think a list of vaccine products is a great idea; such lists are only valid for certain countries, and the approved vaccines vary. Sometimes the same vaccine will appear under different names in different countries, and sometimes what appears to be the same vaccine (same route, dose, manufacturer, presentation) will in fact be different products). I would propose not having a section of approved vaccines --Synaptophysin (talk) 16:44, 20 February 2014 (UTC)

Selected Publications on Influenza Vaccine Effectiveness - CDC
Selected Publications on Influenza Vaccine Effectiveness - CDC

On effectiveness, benefits, consider: What, in Fact, Is the Evidence That Vaccinating Healthcare Workers against Seasonal Influenza Protects Their Patients? A Critical Review, Int J Family Med. 2012; 2012: 205464, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502850/

Contra the benefits section, might not hurt to note this: http://www.ncbi.nlm.nih.gov/pubmed/22895945 --  "Studies funded from public sources were significantly less likely to report conclusions favourable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies."

On safety / side effects: possible link to miscarriage -- http://het.sagepub.com/content/32/5/464.full — Preceding unsigned comment added by 24.166.69.250 (talk) 02:16, 14 October 2014 (UTC)

The neutrality of this article is disputed
From an interview in the Guardian:

I ask Tom Jefferson, the lead author of the Cochrane Review on Vaccines for Preventing Influenza in Healthy Children, which looked at findings from 75 studies, if I should give my four-and-a-half-year-old the nasal vaccine spray.

''“No,” he says, because the trials show a reporting bias on the harms of the live attenuated influenza vaccine (the form of vaccine delivered nasally). “Influenza vaccines are about marketing and not science,” he says. “We have few trials, and masses of very poor quality observational evidence. We have presented evidence of considerable reporting bias, which governments continue to ignore. The science is missing and so making an informed decision is very difficult.''

http://www.theguardian.com/lifeandstyle/2014/oct/05/government-wrong-nasal-spray-vaccine 109.66.55.9 (talk) 07:45, 20 October 2014 (UTC)
 * We are more than happy to cite Dr. Jefferson's systematic reviews and meta analysis which we already do 7 times, but we do not cite guardian for medical content. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 08:09, 20 October 2014 (UTC)


 * Positive info on the vaccine from these kind of sources are indeed cited in the article:
 * Reference34 NY Times: It has been assumed, but not definitively proven, that vaccination provides lifelong protection against the specific strains in the vaccine
 * R59 NYT: In one study of the elderly, flu vaccines cut the risk of death from influenza in half, and reduced the chance of hospitalization by more than a quarter.
 * R67 NYT: Vaccination of school-age children has a strong protective effect on the adults and elderly with whom the children are in contact.
 * R70 NYT The study found that following the 2006 recommendation, the proportion of ER visits for influenza-like illness among 2- to 4-year-olds declined in Boston relative to the proportion of ER visits for influenza-like illness among 2- to 4-year-olds in Montreal.
 * R78 NYT On January 17, 2013, the U.S. FDA approved Flublok, a faster-turnaround influenza vaccine which is the first grown in insect cells instead of eggs. It will be available in the 2013-14 season for people age 18-49, and avoids the problem with egg allergies.
 * R83 NYT A review has concluded that the 2009 H1N1 ("swine flu") vaccine has a safety profile similar to that of seasonal vaccine.
 * R92 ESPN
 * R93 Passporthealthusa.com
 * R102 CTV
 * R108 NBC news
 * R133 The Sunday Times
 * R151 VaccineNewsDaily
 * R167 BBC News
 * R174 The Huffington Post
 * R192 NYT


 * I am returning the Neutrality Template. 109.66.55.9 (talk) 09:53, 20 October 2014 (UTC)
 * Thanks have trimmed the popular press supporting medical content. The use of popular press to support historical issues is not really a problem. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 10:08, 20 October 2014 (UTC)

Some sources of perceived bias: 1. The intro should not include the CDC's recommendation. Informational articles should not contain a call to action. 2. Medical uses should not begin with CDC claim. Same reason. State the facts about medical uses not that 'you' should go out and buy one. 3. No mention of study bias, see link in my talk above. 4. Arguably the CDC recommendations should be proscribed as well as popular media for medical information. http://en.wikipedia.org/wiki/Regulatory_capture#United_States_examples CDC specifically:  http://www.reuters.com/article/2009/12/21/us-merck-gerberding-idUSTRE5BK2K520091221  — Preceding unsigned comment added by 24.166.69.250 (talk) 01:50, 28 October 2014 (UTC)

Needs to begin with explaining the problem it solves
There is a flu vaccine because there is a Flu season and every year a lot of people are at risk of sickness, hospitalization, or death.

This background is essential to the weighing of costs and benefits; how, e.g., the tiny risks arising from flu vaccine are incomparably less than the rather large risks involved in catching influenza, at best debilitating and at worst a deadly disease, both on the individual and the societal level.

This needed background -- flu kills, causes Guillain–Barré syndrome etc. -- was present in earlier versions of this article, and can probably be restored from the history section. — Preceding unsigned comment added by 99.190.133.143 (talk) 23:08, 22 December 2014 (UTC)

List of Immunization "opt out" by State / Country
Does anyone know if there is a Wikipedia article that lists the "opt out" & "mandatory requirements" for each state in USA or each country in the world? If it doesn't exist, then it needs to be created. • Sbmeirow  •  Talk  • 08:44, 5 February 2015 (UTC)

List of Vaccines
The list of vaccines is very short, and really doesn't capture what is available, nor the varying names of these products. I don't think that we need to have a list, as it is difficult to do justice to it. Just off the top of my head I can add Fluad, Agriflu, Influvac, Intanza, Vaxigrip, Flumist, Fluviral, Flucelvax, Flublok, quadrivalent versions of some of these, as well as noting that they go by different names in other countries (e.g., Fluviral is FluLaval; Flumist is Fluenz in Europe, Agrippal is Agriflu in Europe).

With different names in different areas (and the inability to tell if they really are the same vaccine or if they are slightly different) and the increasing numbers of these, I'm not sure that it makes any sense to try to list them. Listing those available for a given country (or countries) might work, but could result in a much longer list with much repetition. --Synaptophysin (talk) 18:39, 2 March 2015 (UTC)

CDC removal
Regarding the removal of CDC recommendations by an IP user: much of the mainstream media coverage of the vaccine mentions governmental guidelines; therefore such recommendations have high WP:WEIGHT and should be featured prominently. In addition, government health-body findings are excellent examples of WP:MEDRS. Wikipedia reports on facts; it is a fact that the CDC and other organizations recommend flu shots, therefore Wikipedia reports such facts in proportion to their prominence and importance.

For example, the former text of "According to the CDC, getting the flu vaccine is the best way to protect yourself against the flu and to help prevent its spread throughout the community" is more informative than the proposed text of "The flu vaccine is designed to protect against the flu and to help prevent its spread throughout the community", the latter of which could be said about lots of things, including camphor balls.

But, what do other people think? I'm reverting the removal until we get a consensus to change. Rolf H Nelson (talk) 19:46, 21 December 2014 (UTC)
 * Yes thanks. You notice that this edit is follow by that of a bot which hides it on most of our watch lists.
 * This IPs edit was simply vandalism. Doc James  (talk · contribs · email) 22:47, 21 December 2014 (UTC)

I'm the IP that removed the CDC recommendation, not a bot. Stating "Party A recommends X" is a call to action and more appropriate for an advertisement than for an informative article. It is not neutral. A neutral translation might be "X is effective at doing this or that (with footnote)." If the effectiveness is disputed, then include relevant questioning material. Wiki should provide information, not tell the person what to do with the information. — Preceding unsigned comment added by 24.166.69.250 (talk) 14:59, 27 December 2014 (UTC)

Commenting again because i happened to run across this today. '"The flu vaccine is designed to protect against the flu and to help prevent its spread throughout the community", the latter of which could be said about lots of things' -- indeed, it can be said about many things, including the flu shot. The question is whether the CDC recommendation implies effectiveness and safety. But a government agency's recommendation does neither. — Preceding unsigned comment added by 24.166.69.250 (talk) 15:39, 4 March 2015 (UTC)

IDSA Guidelines: Vaccinate Immunocompromised Patients ‏
Medscape Medical News

IDSA Guidelines: Vaccinate Immunocompromised Patients ‏

Laurie Barclay, MD

December 05, 2013

http://www.medscape.com/viewarticle/815445

Vaccine Effectiveness science - CDC
Vaccine Effectiveness - How Well Does the Flu Vaccine Work? - CDC

Large trial finds high-dose flu shot beneficial for seniors. NEJM study
Incidence dropped to 1.4% in the high-dose vaccination group, vs. 1.9% in the usual-dose vaccination group. Blood titers were also higher in the group receiving the higher-dose vaccine.

Robert Roos | News Editor | CIDRAP News

Large trial finds high-dose flu shot beneficial for seniors

http://www.cidrap.umn.edu/news-perspective/2014/08/large-trial-finds-high-dose-flu-shot-beneficial-seniors

Aug 13, 2014

________________

DiazGranados CA, Dunning AJ, Kimmel M, Kirby D, Treanor J, Collins A, Pollak R, Christoff J, Earl J, Landolfi V, Martin E, Gurunathan S, Nathan R, Greenberg DP, Tornieporth NG, Decker MD, Talbot HK.

Efficacy of high-dose versus standard-dose influenza vaccine in older adults.

N Engl J Med. 2014 Aug 14 371(7):635-45. doi: 10.1056/NEJMoa1315727.

Review -> "After adjusting for bias in meta-analysis seasonal influenza vaccine remains effective in community-dwelling elderly."
Darvishian M1, Gefenaite G1, Turner RM2, Pechlivanoglou P3, Van der Hoek W4, Van den Heuvel ER5, Hak E6.

After adjusting for bias in meta-analysis seasonal influenza vaccine remains effective in community-dwelling elderly.

http://www.ncbi.nlm.nih.gov/pubmed/24768004

See also,

Review Finds Flu Shot Is Still a Good Choice for Seniors

November 12, 2014

(Reuters Health) - The seasonal flu vaccine protects seniors during so-called epidemic seasons, when flu is widespread, according to a review of past studies. ...

http://www.medscape.com/viewarticle/834817?src=wnl_edit_medn_wir&uac=70451CR&spon=34

The "2010–2011 influenza vaccine was 42% effective in reducing laboratory-confirmed influenza hospitalizations among elderly adults."
Jeffrey C. Kwong,1,2,3,5,6 Michael A. Campitelli,1 Jonathan B. Gubbay,4,5,7,8 Adriana Peci,5 Anne-Luise Winter,5 Romy Olsha,5 Robert Turner,1 Laura C. Rosella,1,5 and Natasha S. Crowcroft3,4,5

Vaccine Effectiveness Against Laboratory-Confirmed Influenza Hospitalizations Among Elderly Adults During the 2010–2011 Season

Clin Infect Dis. Sep 15, 2013; 57(6): 820–827. Published online Jun 20, 2013. doi: 10.1093/cid/cit404


 * ... the 2010–2011 influenza vaccine was 42% effective in reducing laboratory-confirmed influenza hospitalizations among elderly adults ...

Split out The "Effectiveness" section
The "Effectiveness" section is very long and there are lots of facets to it (i.e. subgroups for whom the vaccine is or is not effective), so I think it should be split into its own article titled Effectiveness of influenza vaccines. Everymorning  talk  16:53, 14 March 2015 (UTC)
 * The first thing to do would be to improve that section but trimming poorly referenced stuff. Doc James  (talk · contribs · email) 17:57, 14 March 2015 (UTC)

Are flu vaccines safe and effective ?
This is the best review Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission'''.WARNING: This review includes 15 out of 36 trials funded by industry (four had no funding declaration). An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in light of this finding.''' --Neb46545 (talk) 21:15, 23 October 2015 (UTC)
 * There is a 2014 update which concludes "Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women"  Doc James  (talk · contribs · email) 03:10, 24 October 2015 (UTC)


 * However No evidence of association with serious adverse events was found, but the harms evidence base was limited.The overall risk of bias in the included trials is unclear because it was not possible to assess the real impact of bias.

AUTHORS' CONCLUSIONS: Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women. No evidence of association between influenza vaccination and serious adverse events was found in the comparative studies considered in the review. '''This review includes 90 studies, 24 of which (26.7%) were funded totally or partially by industry. Out of the 48 RCTs, 17 were industry-funded (35.4%).''' — Preceding unsigned comment added by Neb46545 (talk • contribs) 15:46, 3 November 2015 (UTC)

Universal vaccine section
This section is one long string of WP:NOTNEWS violations, in my book. I am working on finding some reviews that lay out the big picture of what is going in universal vaccine R&D - progress as well as challenges.

Many groups worldwide are pursuing development of a universal flu vaccine that does not require modification each year. Companies pursuing the vaccine as of 2009 and 2010 include BiondVax, Theraclone, Dynavax Technologies Corporation, VaxInnate, Crucell NV, Inovio Pharmaceuticals, and Immune Targeting Systems (ITS)
 * Research: Universal vaccine

In 2008, Acambis announced work on a universal flu vaccine (ACAM-FLU-ATM) based on the less variable M2 protein component of the flu virus shell. See also H5N1 vaccines.

In 2009, the Wistar Institute received a patent for using "a variety of peptides" in a flu vaccine, and announced it was seeking a corporate partner.

In 2010, the National Institute of Allergy and Infectious Diseases (NIAID) of the U.S. NIH announced a breakthrough; the effort targets the stem, which mutates less often than the head of the virus.

DNA vaccines, such as VGX-3400X (aimed at multiple H5N1 strains), contain DNA fragments (plasmids). Inovio's SynCon DNA vaccines include H5N1 and H1N1 subtypes.

In July 2011, researchers created an antibody, which targets a protein found on the surface of all influenza A viruses called haemagglutinin. F16 is the only known antibody that binds (its neutralizing activity is controversial) to all 16 subtypes of the influenza A virus hemagglutinin and might be the lynchpin for a universal influenza vaccine. The subdomain of the hemagglutinin that is targeted by FI6, namely the stalk domain, was actually successfully used earlier as universal influenza virus vaccine by Peter Palese's research group at Mount Sinai School of Medicine.

Other vaccines are polypeptide based.

By 2010 some universal flu vaccines had started early stage clinical trials.
 * BiondVax identified 9 conserved epitopes of the influenza virus and combined them into a recombinant protein called Multimeric-001 (M-001). M-001 is aimed at all types of seasonal and pandemic influenza and as of March 2016 is in late Phase 2b clinical trials in Europe and the USA.
 * Dynavax have developed a vaccine N8295 based on two highly conserved antigens NP and M2e and their TLR9 agonist, and started clinical trials in June 2010.
 * ITS's fp01 includes 6 peptide antigens to highly conserved segments of the PA, PB1, PB2, NP & M1 proteins, and has started phase I trials.

Based on the results of animal studies, a universal flu vaccine may use a two-step vaccination strategy — priming with a DNA-based HA vaccine followed by a second dose with an inactivated, attenuated, or adenovirus-vector–based vaccine.

Some people given a 2009 H1N1 flu vaccine have developed broadly protective antibodies, raises hopes for a universal flu vaccine.

On February 13, 2013, U.S. Food and Drug Administration (FDA) Chief Scientist Jesse Goodman predicted that a universal flu vaccine was still 5 to 10 years away. When asked about the prospects of a universal flu vaccine in a hearing before House Energy and Commerce Subcommittee on Oversight and Investigations, Goodman replied "Nature is very tricky and as this is a very crafty virus, so I'd be very hesitant to predict... I think the earliest we'd begin to see something with clinical benefit might be 5 to 10 years."

A 'vaccine'/antigen based on the hemagglutinin (HA) stem was the first to induce 'broadly neutralizing' antibodies to both HA-group 1 and HA-group 2 influenza in mice.

- Jytdog (talk) 14:36, 12 April 2016 (UTC)


 * It would be great to summarise any reviews of this area but I disagree that the above is "one long string of WP:NOTNEWS violations". - This a difficult problem and the slow progress on the many varied approaches deserves mention - at least until a good one is approved for general use. The information could be better presented but very little of it is yet clearly unimportant. Please identify any of it that you think should be removed, so it can be discussed. The summary in this article can be quite short, but most of the above IMO should be covered in the split out article. - Rod57 (talk) 11:23, 13 April 2016 (UTC)

Proposed split out of Universal flu vaccines
This section would split out nicely. It already has lots of refs and needs to be updated and is an active area of research (rather than standard medical practice). - Rod57 (talk) 12:02, 13 March 2016 (UTC)
 * I saw a notice about this at WikiProject Medicine's talk page. I agree with you - this coverage is too detailed for this general article but would be appropriate in its own article. I copied content to User:Bluerasberry/Universal flu vaccine, moved text around, and placed a request to move that draft into article mainspace. This article should briefly present this concept, and in its own article, there can be information about which independent companies did what primary research in the field.  Blue Rasberry   (talk)  14:35, 12 April 2016 (UTC)
 * - thanks for removing the content. Please comment on the spin-off, if you would.  Blue Rasberry   (talk)  14:37, 12 April 2016 (UTC)
 * Not with that content! It is just string of blurbs.  Am working on writing something encyclopedic now... Jytdog (talk) 14:53, 12 April 2016 (UTC)
 * The content at User:Bluerasberry/Universal flu vaccine looks good. (We should add a link back to Influenza vaccine in the intro). I feel we may be giving undue coverage to the single prediction of 5-10 years from 2013. (We could drop the 2nd long sentence and just leave the first with the ref.) There may be earlier and other predictions we could add (briefly). Later, Perhaps we can find a review which discusses the various approaches and their progress. - Rod57 (talk) 11:40, 13 April 2016 (UTC)
 * Like Jytdog said, it is a lot of blurbs. I did not cut anything. It is just a starting point to track the history of development.  Blue Rasberry   (talk)  12:02, 13 April 2016 (UTC)

News?
In my view the following is unremarkable and including it goes against WP:NOTNEWS. This was a local case, appealed to a state appeals court, under state law. Unclear in the sources (or to me) if that has much longer term or broader significance; seems very routine. Was added here with edit note "Added information on a landmark court case about the flu vaccine". As I said the source says nothing about "landmark" and I don't see that either.

A clerk at the McPherson Hospital in McPherson, Kansas was fired from her job and later denied unemployment benefits because they refused to get a flu shot. The case was heard in April of 2016 by the Kansas Court of Appeals where the three-judge panel unanimously affirmed an earlier lower court's dismissal of the employee from the hospital's emergency department.

what do folks think? Jytdog (talk) 22:13, 2 May 2016 (UTC)
 * Agreed. It wasn't clear to me if this had any broad significance either. If it becomes a landmark case, I'm sure secondary sources on vaccine compliance will start to mention it as such. If someone can find those types of sources, I'd feel more comfortable including it. Happy to talk about it if anyone disagrees. Ajpolino (talk) 02:34, 3 May 2016 (UTC)
 * Agree it isn't noteworthy enough to be included, agree point by point with .  02:36, 3 May 2016 (UTC)

Notice of Edit warring noticeboard discussion
Hello. This message is being sent to inform you that there is currently a discussion involving you at Administrators' noticeboard/Edit warring regarding a possible violation of Wikipedia's policy on edit warring. Thank you. seaniz (talk) 11:56, 15 November 2016 (UTC)

'New' articles that bring a new light to the flu vaccine
I know, typically the keepers of pages like this have already decided what they think is important but there is plenty of source material that can help you to see the flu vaccine for what it truly is ... PR, not much more

https://www.google.ca/amp/www.cbc.ca/amp/1.1287363?client=safari seaniz (talk) 12:17, 14 November 2016 (UTC)

Also, here are many more news articles which bring into question the flu vaccine you just have to want to find it. seaniz (talk) 12:26, 14 November 2016 (UTC)

There not here seaniz (talk) 12:27, 14 November 2016 (UTC)
 * Please read WP:MEDRS. We do not use the popular press for medicine. Doc James  (talk · contribs · email) 17:33, 14 November 2016 (UTC)

The article I quoted was a link from the press ... true enough. But if you were to read the article you would see a reference to the study that inspired the journalist to write the story. NOT the same thing as using the popular press for medicine but, of course, I wasn't expecting anybody here to be open minded or, dare I say it, able to read ... — Preceding unsigned comment added by Seaniz (talk • contribs) 20:59, 14 November 2016 (UTC)
 * doesn't matter. popular press is not MEDRS and there are lots of reasons for that. Jytdog (talk) 22:53, 14 November 2016 (UTC)
 * Yes no worries none of us here are able to read. Doc James  (talk · contribs · email) 00:55, 15 November 2016 (UTC)
 * I'm going to commend the editors here on this excellent work on Wikipedia despite being unable to read. Truly inspirational. Natureium (talk) 18:41, 15 November 2016 (UTC)
 * Thanks :-) Doc James  (talk · contribs · email) 00:21, 16 November 2016 (UTC)

Yeah, I would also like to commend the editors of this page for using a study that categorically denies the usefulness of the influenza vaccine in healthy adult populations to justify the claim that healthy adults should get the influenza vaccine because it will help them. seaniz (talk) 11:54, 16 November 2016 (UTC)

The true conclusions of the Cochrane metastudy
I noticed that some of the citations in the 'Adults' section mentioning the Cochrane study but citing another source ...? Possibly an error in the edit. But also considering how thoroughly the Cochrane study dismisses the usefulness of the flu vaccine for healthy adults ....

A BIG mistake. I'm not sure what was going through the head of the author. If s/he is here would you mind taking a look and I'm sure you'll notice that this study does NOT support adult influenza vaccination at all. seaniz (talk) 12:03, 14 November 2016 (UTC)
 * You mean this study ? Which states "15.6% of unvaccinated participants versus 9.9% of vaccinated participants developed ILI symptoms, whilst only 2.4% and 1.1%, respectively, developed laboratory-confirmed influenza" Doc James  (talk · contribs · email) 17:31, 14 November 2016 (UTC)

Yes James the link which you give is basically a summary of an abstract .... : https://www.ncbi.nlm.nih.gov/pubmed/24623315

is actually sourced from: http://dx.doi.org/10.1002/14651858.CD001269.pub5

and then if you choose to read the full text of the study: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub5/full

that last link is where you find the relevant information from the study like:

Implications for practice

The results of this review provide no evidence for the utilisation of vaccination against influenza in healthy adults as a routine public health measure. As healthy adults have a low risk of complications due to respiratory disease, the use of the vaccine may only be advised as an individual protective measure.

seaniz (talk) 21:08, 14 November 2016 (UTC)
 * this was not an improvement in any way. that edit replaced newer reviews with older ones, referred to the Cochrane review as a "meta study" (i think "meta-analysis" is what was intended), and other problems.  Oy. Jytdog (talk) 22:58, 14 November 2016 (UTC)

That is absolutely false Jytdog. Follow the link from the source on the page to the actual study http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub5/full

scroll ALL THE WAY DOWN to the bottom where it says "Implications for Practice" they are the same study only you folks think the 16% TO 10% AND 2.4% to 1.4% are more useful than the recommendations they make at the END of the study where they say that healthy adults shouldn't get the flu vaccine because that would be a waste of resources.

Honestly, I can't believe that you're calling my quote from the VERY same study outdated! seaniz (talk) 10:09, 15 November 2016 (UTC)
 * In the dif I gave above you deleted a 2014 NEJM ref and content based on it, and replaced it with content sourced to a 2011 paper. why in the world would you do that? Jytdog (talk) 10:52, 15 November 2016 (UTC)

false. I did not do that. My reference is from 2014 and I didn't delete any references. seaniz (talk) 10:55, 15 November 2016 (UTC)
 * Yes you did. look at the dif - down in the pregancy section.  Jytdog (talk) 11:17, 15 November 2016 (UTC)

can you provide any evidence that the article I used was from 2011? the link I have consistenly used is as follows: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub5/full seaniz (talk) 11:22, 15 November 2016 (UTC)

btw .... followed the link in the pregnancy section that you linked to ... it was dated 2014 March 13! not 2011 as you suggested — Preceding unsigned comment added by Seaniz (talk • contribs) 11:25, 15 November 2016 (UTC)
 * this is the paper you added in that dif; from 2011. I have given you notice of discretionary sanctions on PSCI and you have already gone way over 3RR.  I will talk with you when your block is over and you are ready to work through these issues. Jytdog (talk) 11:40, 15 November 2016 (UTC)

I`ve never seen the article to which you link above. do you have some evidence that I linked to it? Listen JYtdog ... my addition of the author's conclusions from the very same study that was referenced in the adult section is PERFECTLY reasonable. I can't honestly see why you constantly remove the author's conclusions ... not happy with the conclusions? too bad, they come together with the other data that you continue to replace in that section. just read to the end of the study and I promise you'll find the conclusions there ... use the bar on the right of your screen to scroll to the bottom of the article. the same article I have been quoting since I began trying to fix this silly excuse for information on the influenza vaccine. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub5/full seaniz (talk) 11:51, 15 November 2016 (UTC)
 * I copied it from your dif . Jytdog (talk) 11:54, 15 November 2016 (UTC)

In point of fact the link in question was in the article before I edited it ... the fact that I did NOT remove it is evidence that my editing is much more inclusive than yours. Instead of removing links that were there, I added links and information that were NOT included in the article in order to make the article better. seaniz (talk) 12:22, 15 November 2016 (UTC)
 * I'm not sure what the logic is in that reasoning, and capitalizing words doesn't make people agree with you. Natureium (talk) 18:39, 15 November 2016 (UTC)

EMPHASIS. Would somebody please explain to me why the authors conclusions from the same study used for the figures in the adult section  gets removed whenever I add it in? Like I said before you do need to follow the link in the article to the FULL study and then scroll to the bottom to discover the conclusions: The Influenza vaccine is effectively a waste of resources when it comes to the vaccination of healthy adults concluded the Cochrane Collaboration authors of a meta-analysis last updated March 13, 2014:

"The results of this review provide no evidence for the utilisation of vaccination against influenza in healthy adults as a routine public health measure. As healthy adults have a low risk of complications due to respiratory disease, the use of the vaccine may only be advised as an individual protective measure". seaniz (talk) 20:18, 15 November 2016 (UTC)
 * Hello seaniz, I recently reverted your new text. I'm sorry to see that you're frustrated with the way things are working here. If you read the authors' conclusions from their abstract (i.e. the conclusions of the paper) they say:

""Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women. No evidence of association between influenza vaccination and serious adverse events was found in the comparative studies considered in the review. This review includes 90 studies, 24 of which (26.7%) were funded totally or partially by industry. Out of the 48 RCTs, 17 were industry-funded (35.4%).""


 * In short:


 * 1) Influenza vaccines are (only) modestly effective (in "Main Results" they report "15.6% of unvaccinated participants versus 9.9% of vaccinated participants developed ILI symptoms")
 * 2) Influenza vaccines are not found to be associated with serious adverse events
 * 3) Of the randomized clinical trials (RCT) available, they break down how many were funded partially or entirely by industry groups.
 * They do not claim that vaccinations are a waste of resources. This review is meant to assess the effect of influenza vaccines on development of influenza-like illness. It does not assess the cost-effectiveness of vaccinating the population. As such, it wouldn't make sense for us to make claims about the cost-effectiveness of the vaccine based on this review. I hope that helps to clear things up. Happy editing! Ajpolino (talk) 21:21, 15 November 2016 (UTC)

@Ajpolino I'm sure you haven't missed the point I'm trying to make I just think I should try to place it in context here:

All of the following quotes are from the article you referenced above @ajpolino: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub5/full

"Why it is important to do this review Given the very high cost of yearly vaccination for large parts of the population, the extreme variability of influenza incidence during each 'season' and the heterogeneity of public health recommendations, we carried out a systematic review of the evidence. To enhance its relevance for decision-makers, in the 2007 update of the review we included comparative non-randomised studies reporting evidence of serious or rare harms (or both) (Jefferson 2007). In the present update (2013), we have also included evidence about influenza vaccination in pregnant women and newborns."

So, to summarize ... using the influenza vaccine on the entire population (healthy adults, pregnant women, the elderly ... etc.) is expensive but there are extremely variant results from season to season

"Implications for practice

The results of this review provide no evidence for the utilisation of vaccination against influenza in healthy adults as a routine public health measure. As healthy adults have a low risk of complications due to respiratory disease, the use of the vaccine may only be advised as an individual protective measure."

To summarize ... healthy adults should not get the influenza vaccine because there are extremely minimal benefits (elsewhere in the study you find that the healthy adults who were vaccinated on average spent 0.04 less time off sick due to influenza related illness that amounts to about 18 minutes per adult).

High cost + no measurable reward = why are we giving the influenza vaccine to healthy adults again?

No, the authors do not say that the influenza vaccine is a "waste of resources" but they do say that the vaccines cost a lot of money and there is no measurable benefit ... isn't that precisely the same thing?

A final note: @Ajpolino:

you stated that the Authors' conclusions were:

"Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women. No evidence of association between influenza vaccination and serious adverse events was found in the comparative studies considered in the review. This review includes 90 studies, 24 of which (26.7%) were funded totally or partially by industry. Out of the 48 RCTs, 17 were industry-funded (35.4%)."

In fact this is the ABSTRACT not the authors' conclusions but the summary of the authors' conclusions:

I don't want to be rude but say this for emphasis, SCROLL ALL THE WAY DOWN to the bottom of the study (well, shy of the Acknowledgements and etc.) to see the ACTUAL Authors' conclusions (my emphasis added with the '*'s):

"Authors' conclusions

Implications for practice

The results of this review provide *no evidence* for the utilisation of vaccination against influenza in healthy adults as a routine public health measure. As healthy adults have a low risk of complications due to respiratory disease, the use of the vaccine may only be advised as an individual protective measure.

Implications for research

The major differences in effect sizes between outcomes highlight the need for careful consideration of the best study design to assess the effects of public health measures such as vaccination. Large studies, encompassing several influenza seasons, are required to allow assessment of the effect of the vaccines on rare outcomes such as complications and death."

In other words: this study finds that there is no reason to vaccinate healthy adults ("the results of this review provide no evidence for the utilisation of vaccination against influenza in healthy adults")

Sounds kind of like: 'In healthy adults influenza vaccination is a waste of resources'

doesn't it?

Thank you @ajpolino for being so outgoing and trying to reach out to me in this. You ARE the only one. Everybody else simply dismissed me and misunderstood me. I'm hoping that this helps you to understand my point. I also don't want to be harsh but find it difficult to avoid being truthful so I hope I didn't hurt your feelings by pointing out your mistakes. seaniz (talk) 11:49, 16 November 2016 (UTC)

Why is everyone jumping all over Seaniz for a relevant, albeit awkwardly worded edit? It is an important and non-controversial point that finding evidence of a benefit for influenza vaccine in healthy adults has been hard, and consequently routine vaccination for them wasn't recommended in the US until 2010 (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5908a1.htm) despite decades of study up to that point. Only after the nasty 2009 H1N1 outbreak that hit younger adults disproportionately and economic analyses like (https://www.ncbi.nlm.nih.gov/pubmed/17544181) that showed a tremendous economic burden for influenza did the CDC and ACIP agree to recommend that healthy adults get the vaccine. The current thinking is there's a small absolute benefit but with the huge annual burden and the potential for serious badness if a repeat of the 2009 H1N1 comes around, it's probably worth it. Pgcudahy (talk) 18:22, 16 November 2016 (UTC)


 * If he hadn't made 17 edits in 2 days that were reverted by 5 different people who explained why his edits were being removed, while insisting that he was right and everyone else was wrong, people might be less harsh. Natureium (talk) 18:33, 16 November 2016 (UTC)

actually, Natureium most of my edits were reverted WITHOUT a valid criticism. the only one that cane close was Ajpolino (on our talk pages) everybody else is falsely claiming i used an older study, claiming i misquoted the study (patently false). it's ok, i understand that you folks ignore me because you mistakenly believe I'm wrong. Not a single one of you has manned up to the fact that this article is using a study that shows NO EVIDENCE in favour of vaccinating healthy adults against the flu, in order to support multiple reverts that recommend all adults to get the flu vaccine. just because there are Five of you doesnt make you correct. seaniz (talk) 20:56, 16 November 2016 (UTC)


 * I'm not sure what seaniz has edited, but if he is accurately quoting the body of the article in question - that should take precedence over anything mentioned in the abstract. Seaniz does have to realise though Wikipedia is a tertiary source, thus using a secondary source that uses data from a primary source to reach other conclusions than the original authors is fair game. However the test of the original authors should certainly be taken in consideration.ZayZayEM (talk) 09:03, 18 November 2016 (UTC)
 * Not dealing with anything but your middle sentence. We absolutely do not read against what the authors of a paper say themselves!  That is not "fair game" it is policy-violating WP:OR. Jytdog (talk) 09:08, 18 November 2016 (UTC)

Then how do you explain all those reverts suggesting that there is some benefit to adults using the flu vaccine?seaniz (talk) 03:16, 19 November 2016 (UTC) seaniz (talk) 03:16, 19 November 2016 (UTC)

Tamiflu part II
So, we had kind of a battle about a year ago over Tamiflu, another situation where Jefferson-led reviews contradicted mainstream medical practice. We came to an OK resolution there, where we presented Jefferson's views and actual, mainstream medical practice, sourced to CDC, WHO, and practice guidelines, with equal WEIGHT. Doc James can we apply that resolution here on this article? thx. Jytdog (talk) 05:51, 19 November 2016 (UTC)
 * The lead says
 * "While their effectiveness varies from year to year, most provide modest to high protection against influenza.[2][3] They decrease the number of missed days of work by a half day on average.[4] Vaccinating children may protect those around them[2] but the effectiveness of the vaccine in those over 65 years old is unknown because the evidence for this group is poor.[5][6] Both the World Health Organization and Centers for Disease Control and Prevention recommends nearly all people over the age of 6 months get the vaccine yearly.[2][7] This is especially true for pregnant women, children between six months and five years of age, those with other health problems, Native Americans, and those who work in healthcare.[1][2]"
 * Do you have an issue with any of this? Doc James  (talk · contribs · email) 00:18, 20 November 2016 (UTC)

Vaccinations for health careworkers
I would like to update the article with a more recent Cochrane Review (2016 version vs 2013).

Here is my suggested edit: '''Further research is required to determine if vaccinating health care workers working with elderly people helps protect the elderly people from influenza. ref: https://www.ncbi.nlm.nih.gov/pubmed/27251461'''

I propose removing the following from the Elderly section of this article: "A 2013 Cochrane review found that the same benefit did not extend to vaccinating health care workers working with elderly patients in long-term care facilities.[38]"

I find the present wiki article statement from the 2013 review too strong for the conclusion of the 2016 review. Please let me know if you have the same interpretation of the results.

Here are the authors conclusions (quoted): "Our review findings have not identified conclusive evidence of benefit of HCW vaccination programmes on specific outcomes of laboratory-proven influenza, its complications (lower respiratory tract infection, hospitalisation or death due to lower respiratory tract illness), or all cause mortality in people over the age of 60 who live in care institutions. This review did not find information on co-interventions with healthcare worker vaccination: hand-washing, face masks, early detection of laboratory-proven influenza, quarantine, avoiding admissions, antivirals and asking healthcare workers with influenza or influenza-like illness (ILI) not to work. This review does not provide reasonable evidence to support the vaccination of healthcare workers to prevent influenza in those aged 60 years or older resident in LTCIs. High quality RCTs are required to avoid the risks of bias in methodology and conduct identified by this review and to test further these interventions in combination." https://www.ncbi.nlm.nih.gov/pubmed/27251461

Thanks. JenOttawa (talk) 13:01, 19 November 2016 (UTC)
 * Please hold off on giving yet more WEIGHT to Jefferson, per the section above.  Sometimes we get reviews discussing evidence that contradict actual practice, and when that happens we need to work it through. Jytdog (talk) 13:47, 19 November 2016 (UTC)
 * Replacing an older review with a newer one is not changing the weight.
 * The results also say "HCW vaccination probably leads to a reduction in lower respiratory tract infection in residents from 6% to 4% (RD -0.02 (95% CI -0.04 to 0.01), one study of 3400 people; moderate quality evidence)"
 * While no conclusive evidence there is tentative evidence of benefit. Doc James  (talk · contribs · email) 00:19, 20 November 2016 (UTC)
 * looks ok(abstract...full text?)--Ozzie10aaaa (talk) 02:01, 20 November 2016 (UTC)
 * Are there other reviews that address this question? I'm leery of interpreting "This (one) review did not find information on" any subject and writing "no such information exists".  I think I'd rather have the article be silent on this point, than to overstate the certainty based on any single paper (in either direction).  WhatamIdoing (talk) 05:17, 22 November 2016 (UTC)


 * I think that it is important to add in the new 2016 Cochrane review (update the 2013 review), but I also agree that adding in either another review or a public health policy fact, would be helpful for wikipedia readers. Ultimately, I feel that it comes down to the goal of this wikipedia article. Why are we writing it, and who is it for? I am a new editor, so I am still learning in this regard.

I will give the revision my best try! What about something like this:

'''Vaccinating health care workers who work with elderly people is recommended or mandated in many countries (REF), with the goal of reducing influenza outbreaks in this vulnerable population. While there is no conclusive evidence from randomized clinical trials that vaccinating health care workers helps protect the elderly people from influenza, there is tentative evidence of benefit. ref: https://www.ncbi.nlm.nih.gov/pubmed/27251461'''

If the consensus is to make this revision, what type of citation do you recommend for the public policy sentence? Here are some examples of what I have been reading. http://www.cdc.gov/flu/healthcareworkers.htm http://www.phac-aspc.gc.ca/naci-ccni/flu-2016-grippe-eng.php#iii2 http://www.who.int/influenza/vaccines/use/en/

Another option would be to move the reference from Cochrane to the "Research" section of the wiki article, and leave the policy statement in the "Elderly" section. This may be easier for people to interpret.

I will wait for feedback before making the change. Thanks. JenOttawa (talk) 14:52, 23 November 2016 (UTC)
 * looks good, informative for the reader and well sourced!--Ozzie10aaaa (talk) 15:15, 23 November 2016 (UTC)


 * I have taken a closer look at the structure of the wiki article. There is a good section on policies in different countries and in the WHO. I think I may change my own mind on my suggested revision! CDC, Health Canada, WHO references are already in place earlier in the article.

What about putting in a link like this:

'''Vaccinating health care workers who work with elderly people is recommended or mandated in many countries (see https://en.wikipedia.org/wiki/Influenza_vaccine#Recommendations), with the goal of reducing influenza outbreaks in this vulnerable population. While there is no conclusive evidence from randomized clinical trials that vaccinating health care workers helps protect the elderly people from influenza, there is tentative evidence of benefit. ref: https://www.ncbi.nlm.nih.gov/pubmed/27251461'''

Despite the same info being mentioned earlier in the same wiki article, I feel that it is important to re-state the recommendations along with the results of the cochrane review in the "Elderly" section. I will put the re-direct link in properly in the actual edit, my computer is acting up. I will still wait for more feedback before proceeding. Thanks very much JenOttawa (talk) 17:10, 23 November 2016 (UTC)
 * yes it would help this subsection, the text you suggest above is fine, however you could add more info such as .... which countries is it mandated in and which countries is it just recommended? (for example)--Ozzie10aaaa (talk) 23:39, 23 November 2016 (UTC)
 * Are their countries that mandate it? Doc James  (talk · contribs · email) 04:49, 24 November 2016 (UTC)
 * , (brief mention)--Ozzie10aaaa (talk) 12:03, 24 November 2016 (UTC)
 * Thanks for all the feedback user:ozzie10aaaa, and good point re mandate user:doc James. There seem to be individual facilities that mandate it as well, but i am not certain on this. JenOttawa (talk) 12:20, 24 November 2016 (UTC)
 * Yes individual institutions try to mandate. Our is an either immunize or you are required to wear a mask. Doc James  (talk · contribs · email) 00:13, 26 November 2016 (UTC)

Not correct
This is still not correct "Specifically, they recommend vaccination for high-risk groups such as pregnant women, the elderly, children between six months and five years of age, those with other health problems, those who work in healthcare and others; depending on the health authority." Doc James (talk · contribs · email) 09:01, 26 December 2016 (UTC)
 * They recommend vaccinating all of those over 6 months and than specifically even more strongly recommend vaccinating certain subgroups who are at high risk. Doc James  (talk · contribs · email) 09:03, 26 December 2016 (UTC)

Lead efficacy conclusions
I have initiated changes to the lead paragraph on efficacy from:
 * While their effectiveness varies from year to year, most provide modest to high protection against influenza.[2][3] They decrease the number of missed days of work by a half day on average.[4] Vaccinating children may protect those around them[2] but the effectiveness of the vaccine in those over 65 years old is unknown because the evidence for this group is poor.[5][6]

To: https://en.wikipedia.org/w/index.php?title=Influenza_vaccine&oldid=756428121
 * While their effectiveness varies from year to year, most provide modest protection against influenza.[3] They decrease the number of missed days of work by a half day on average.[4] Overall, the evidence quality is poor,[5] which a cochrane meta analysis cautioned as "widespread manipulation of conclusions and spurious notoriety of the studies".[6] The effectiveness of the vaccine in those under 2 years old and over 65 years old is unknown because the evidence for this group is lacking.[6][3][7]

Reasons:
 * efficacy moderate to high I changed into moderate - Human Vaccines & Immunotherapeutics (impact factor of 3.4) published meta analysis does not get WP:DUE over The Lancet (impact factor 47.x) published meta analysis. Both from 2012.
 * I added the 2 year olds to the 65 years old conclusion statement using the Cochrane meta analysis on efficacy in children.
 * A meta analysis published in BMJ specifically studying the influenza vaccine studies quality, describes them in their conclusion as overall Poor quality.
 * The Cochrane systematic review about children elaborated about why the quality is poor as "widespread manipulation of conclusions and spurious notoriety of the studies.

Jytdog has reverted me with the comment "UNDUE weight to dissenter's POV. Already discussed on Talk." Dissenters? Is this a joke? These are the leading studies and researches in the field Bigbaby23 (talk) 05:17, 24 December 2016 (UTC)


 * Since no objections, I have added a modified version to the lead:
 * While their effectiveness varies from year to year, most provide modest protection against influenza.[3] The evidence quality is poor; studies with favourable conclusions about efficacy were of significantly lower methodological quality.[4] They decrease the number of missed days of work by a half day on average.[5] Vaccinating children may protect those around them[2] but the effectiveness of the vaccine in those under 2 years old and over 65 years old is unknown due to low quality research.[6][3][7]Bigbaby23 (talk) 01:56, 25 December 2016 (UTC)


 * Doc James, what are your reasons for:
 * Rejecting the Lancet published meta review that states "moderate efficacy" over a systematic review from a journal of factor 3.x that states "moderate to high"?
 * Rejecting the description of the quality of the studies from the BMJ meta analysis of the studies quality ? Bigbaby23 (talk) 16:14, 25 December 2016 (UTC)
 * Some high quality reviews say modest others say high, so we have listed "modest to high" to account for the range of opinions. Doc James (talk · contribs · email) 09:06, 26 December 2016 (UTC)


 * But with this phrasing it appears the article is giving equal validity to the major high quality reviews and the others. This is specifically troublesome, when there is due weight criticism about the studies quality and bias as a whole.
 * Why are you rejecting a high quality review published in BMJ, studying the wuality of research and concluding them as poor quality etc?Bigbaby23 (talk) 14:27, 26 December 2016 (UTC)

Evidence of poor quality
We say "Vaccinating children may protect those around them." Therefore this can go in the body "Overall, the evidence quality is poor; studies with favourable conclusions about efficacy were of significantly lower methodological quality. "

This is undue weight in the lead "Data on adverse effects are scant." The vaccine has been used millions of times. Doc James (talk · contribs · email) 06:17, 31 December 2016 (UTC)


 * For the sake of clarity, this is where I had placed the additions in the lead:

Influenza vaccines, also known as flu shots, are vaccines that protect against influenza.[2] A new version of the vaccine is developed twice a year as the influenza virus rapidly changes.[2] While their effectiveness varies from year to year, most provide modest to high protection against influenza.[2][3] They decrease the number of missed days of work by a half day on average.[4] Vaccinating children may protect those around them.[2] Overall, the evidence quality is poor;[5][6] studies with favourable conclusions about efficacy were of significantly lower methodological quality.[5] The effectiveness in those under 2 years old and over 65 years old is unknown due to the low quality of the research.[7][8][9]

Data on adverse effects are scant.[6] The vaccines are generally safe;[2] In children, fever occurs in 5 to 10%, as may muscle pains or feeling tired. In certain years, the vaccine causes Guillain–Barré syndrome in older people in about one per million doses. It should not be given to those with severe allergies to eggs or to previous versions of the vaccine. The vaccines come in both inactive and weakened viral forms. The inactive version should be used for those who are pregnant. They come in forms that are injected into a muscle, sprayed into the nose, or injected into the middle layer of the skin.[2]


 * The "Overall" references are not specifically about that sentence. They are describing the entire body of efficacy research /paragraph:
 * BMJ 2009 Systematic review - "What this study adds: Evidence is of poor quality, and studies with conclusions in favour of vaccines are of significantly lower methodological quality"
 * Clinical Microbiology & Infectious Diseases 2014 Systematic review - "generally, the quality of the studies was low"


 * The 2014 review finds it important to state that very little research has been done on the subject "Data on adverse effects were scarce." After that we have the WHO2012 describing the conclusion of that research. There is no conflict, or Undue Weight issue.Bigbaby23 (talk) 07:59, 31 December 2016 (UTC)
 * nothing about this is particularly European. this tag justification makes no sense. It does give UNDUE weight to Tom Jefferson's views, who is an outlier among people who work on vaccines.  That is discussed in the Society and culture section, which by now you have probably read. Jytdog (talk) 15:28, 31 December 2016 (UTC)


 * The template is in response to the discussion in the recommendation lead summary section sub-category "third draft".
 * Jefferson doesn't "work on vaccines" he is the lead reviewer of the leading Institute in the world on meta analysis.   Osterholm who supports using the vaccine, states the same conclusion on the quality of the studies. That's why it has a second ref. These two together have Weight. That's why they are also used and quoted for the "effectivnesd over 65 year old is unknown" in the lead.Bigbaby23 (talk) 03:31, 1 January 2017 (UTC)
 * you are not reading the sources cited in the society and culture section; describes his outlier status very clearly. Jytdog (talk) 04:11, 1 January 2017 (UTC)
 * According to you, we should remove the whole Cochrane meta analysis reviews and CIDRAP (Osterholm) from this article, since authorities continue to ignore and reccomend the vacvine to groups that meta analysis conclude have no quality research. But wait.. the first paragraph is a summary of the research authorities and the second the policy makers reccomendation. It is not wikipedia's job to have a POV on this seeming conflict. Just report it.Bigbaby23 (talk) 15:45, 1 January 2017 (UTC)
 * never said that, no. Jytdog (talk) 00:26, 2 January 2017 (UTC)

Criticism
This "Policy makers have been criticized by leading researchers for the discrepancy between the scientific evidence and the promotion of the vaccine. IMO is good enough in the body. We already say the evidence in the young and old is poor in the paragraph above. Doc James  (talk · contribs · email) 13:49, 25 December 2016 (UTC)

Yes, in the body for sure. After we settle on the reccomendation paragraph, we'll come back to discuss thisBigbaby23 (talk) 14:37, 26 December 2016 (UTC)
 * It was already in the body before you made your first edit here. Jytdog (talk) 19:51, 26 December 2016 (UTC)


 * Oh i didn't understand the "culture and society" reference as a section. Alright.Bigbaby23 (talk) 08:20, 30 December 2016 (UTC)
 * You added it in the correct section after all - thanks. My apologies for reverting etc. Jytdog (talk) 18:22, 30 December 2016 (UTC)


 * No reason stated for revert of more similar informationBigbaby23 (talk) 22:46, 3 January 2017 (UTC)
 * about this, WP:UNDUE has been cited to a zillion times. Jefferson's position on clinical trials is probably FRINGE is a minority position at best and you are giving it way, way UNDUE weight. And we do not do endless tit for tat from FRINGE/minority advocates.  We state his position and describe the mainstream view and that is all we need. Jytdog (talk) 00:27, 4 January 2017 (UTC)


 * and this edit note is an error that junior high school students make. An author states positions in articles that journals publish.  Journals rarely "say" anything; their editorial boards sometimes do.  This is not that. Jefferson =/= Cochrane.  Not by very, very far. Jytdog (talk) 03:51, 4 January 2017 (UTC)


 * Has been cited by you a zillion times. It doesn't make it so. Jefferson is stating Cochrane's position. "There's no way that the Cochrane Collaboration can compete with governments." That ain't no FRINGE buddy.
 * And the other additions are regarding criticism of over promotion by leading figures; American Osterholm, European Jefferson and Australian Collignon.
 * Do not abuse WP:DUE or I will push for a Criticism section.Bigbaby23 (talk) 03:56, 4 January 2017 (UTC)

For the sake of ease here are the paragraphs in the "Culture and Society#Evaluation of Evidence" section with my additions: Tom Jefferson, who has led Cochrane Collaboration reviews of flu vaccines, has called clinical evidence concerning flu vaccines "rubbish" and has therefore declared them to be ineffective; he has called for placebo-controlled randomized clinical trials. His views on clinical trials are considered unethical by mainstream medicine and his views on the efficacy of vaccines are rejected by medical institutions including the CDC and the National Institutes of Health, and by key figures in the field like Anthony Fauci. In response, Jefferson suggested as an alternative clinical trials with randomization against other forms of proven influenza infection control. As for the rejection of his views Jefferson stated "There's no way that the Cochrane Collaboration can compete with governments."

Michael Osterholm who has led the Center for Infectious Disease Research and Policy 2012 review on flu vaccines recommends getting the vaccine but criticizes its promotion  “We have overpromoted and overhyped this vaccine...it does not protect as promoted. It’s all a sales job: it’s all public relations”. According to Osterholm the expansion in policy of immunization was based on "professional judgment and not on scientifically sound data". According to Tom Jefferson, this is due to policy makers lack of critical appraisal of the methodology quality of studies and citation bias towards studies that show efficacy. According to Peter Collignon it's because of "influential drug companies and frightened politicians".

Bigbaby23 (talk) 06:05, 4 January 2017 (UTC)

Lead recommendation summary
I have now also added under the recommendation summary in the lead, the notable criticism of it by the leading researches: https://en.wikipedia.org/w/index.php?title=Influenza_vaccine&oldid=756434051
 * Leading researchers have criticized the discrepancy between the scientific evidence and the over promotion and hype of the vaccine by policy makers.


 * sources used Tom Jefferson (epidemiologist) in BMJ review, Michael Osterholm in Center for Infectious Disease Research and Policy report. + two supporting references that elaborate more on the above in Scientific American and Center for Infectious Disease Research and Policy News.Bigbaby23 (talk) 05:54, 24 December 2016 (UTC)


 * Where is this discussed in the body of the article?

Leading researchers have criticized the discrepancy between the scientific evidence and the over promotion and hype of the vaccine by policy makers.

-- Jytdog (talk) 06:33, 24 December 2016 (UTC)
 * DoneBigbaby23 (talk) 07:16, 24 December 2016 (UTC)


 * Jytdog has reverted the second addition stating in his revert "edit warrnig woo into articles about health". I cannot take you seriously. This very sentence and references are the ones criticizing the "woo".Bigbaby23 (talk) 06:43, 24 December 2016 (UTC)


 * Jytdog you are again making things WP:TENDENTIOUS like you did to me in the Allicin article, because you wrongfully assumed non good faith. Instead of looking into at what i added. Finally in the Allicin article you realized i was right and not being deceitful. Please let's not go through that againBigbaby23 (talk) 06:48, 24 December 2016 (UTC)
 * We paraphrase rather than quote generally. This was supported by the refs "Both the World Health Organization and Centers for Disease Control and Prevention recommends nearly all people over the age of 6 months get the vaccine yearly" and provided a better overview of the position of major organizations. Doc James  (talk · contribs · email) 08:04, 24 December 2016 (UTC)
 * The paragraph was misleading and lacking. I changed the quotations into paraphrases. Each one is a direct "quote" of the organization own "recommendation" section in their position papers. There is no ambiguityBigbaby23 (talk) 08:29, 24 December 2016 (UTC)

It was not misleading.

WHO states "Annual vaccination (or re-vaccination, if the vaccine strains are identical) is recommended, particularly for high-risk groups." and "Children aged <6 months are not eligible to receive currently licensed influenza vaccines" This means all people should be immunized particularly those at high risk.

CDC states "Everyone 6 months and older is recommended for annual flu vaccination with rare exception" Doc James (talk · contribs · email) 08:36, 24 December 2016 (UTC)


 * I did miss that sentence, which is very strangely placed and some what vaguely worded in that section. I thank you. The EU position should be incorporated too. http://ecdc.europa.eu/en/healthtopics/seasonal_influenza/vaccines/Pages/influenza_vaccination.aspx
 * Please comment on my first additions in this talk section Bigbaby23 (talk) 08:55, 24 December 2016 (UTC)


 * I found a 2016 WHO paper which is more straight forward in it's wording, so there is less potential confusion
 * "RECOMMENDATED TARGET GROUPS FOR INFLUENZA VACCINATION: Vaccination can  benefit all age  groups,  but is  especially  important for  people  at higher  risk of serious  influenza  complications."  http://www.euro.who.int/__data/assets/pdf_file/0003/321843/recommendations-influenza-vaccination-2016-2017-winter-season-en.pdf?ua=1
 * The CDC is the only one actually stating it in a non convoluted way.Bigbaby23 (talk) 09:26, 24 December 2016 (UTC)
 * Have added the position from the EU to the body of the text. Doc James  (talk · contribs · email) 10:47, 24 December 2016 (UTC)

They recommend all people over 6 months be immunized and than they make this recommendation more strongly for certain groups. This is not correct "Specifically, they recommend vaccination for high-risk groups such as pregnant women, the elderly, children between six months and five years of age, those with other health problems, those who work in healthcare and others; depending on the health authority." Doc James (talk · contribs · email) 13:45, 25 December 2016 (UTC)


 * James, I was forced now to look deeper into this. And we have good secondary sources that solve this matter.
 * The WHO and ECDC reccomend targeted vaccination programs while the CDC reccomends a universal vaccination program. (Since 2010 http://www.cidrap.umn.edu/news-perspective/2010/07/cdc-launches-universal-flu-vaccination-recommendation)
 * The WHO 2012 position (primary source) regarding vaccine reccomendation policy is specifically discussed in a WHO 2015 systematic review (also great info on rest of world besides Europe and North America):
 * "In the  US,  the  Advisory  Committee  on  Immunization  Practices  recommends  annual  influenza  vaccination  for everyone  6mo  or  older  if  there  are  no  medical  contra-indications  such  as vaccine  allergy  [33].  The  WHO recommends  targeted  vaccination  against  seasonal  influenza  for  five  priority  groups  viz.  children  aged  6mo  to 5y,  elderly  persons  aged  65y  and  above,  persons  with  specific chronic illness,  pregnant  women,  and  healthcare professionals  [3]" page 17 http://apps.who.int/iris/bitstream/10665/188785/1/9789241565097_eng.pdf&sa=U&ved=0ahUKEwiux--t0Y_RAhXMp48KHXOjDY0QFgghMAE&usg=AFQjCNHk9T9PNJFMxxOpuMGa4yTSuB26Nw
 * The ECDC paragraph you moved to the Europe section, is commentary (secondary source) on the WHO 2012 (new) guidelines. Not just about the ECDC approach http://ecdc.europa.eu/en/activities/sciadvice/_layouts/forms/Review_DispForm.aspx?List=a3216f4c-f040-4f51-9f77-a96046dbfd72&ID=698
 * It is also discussed at length in a CNN article quoting experts and WHO personal http://edition.cnn.com/2013/01/17/health/flu-vaccine-policy/ and links to WHO document like this one http://www.who.int/immunization/sage/meetings/2012/april/1_Background_Paper_Mar26_v13_cleaned.pdf Bigbaby23 (talk) 15:58, 25 December 2016 (UTC)


 * I therefore suggest we use a mix of my previous edits, with some modifications:
 * The World Health Organization the Centers for Disease Control and Prevention and the European Center for Disease Prevention and Control share the general view that vaccination can benefit all age groups above the age of 6 months, as vaccination against influenza is the most effective form of protection against the disease. The influenza vaccination strategy is generally that of protecting vulnerable people, rather than limiting influenza circulation or totally eliminating human influenza sickness. This is in contrast with the high herd immunity strategies for other Infectious diseases such as polio and measles. This is also due in part of the financial and logistics burden due to the need of an annual injection. Both the WHO and the ECDC recommend targeted vaccine programs, while the CDC recommends a univeral vaccine program. The World Health Organization recommends vaccinating pregnant women as the first priority, with secondary priority to risk groups; children aged 6–59 months, the elderly, people with specific chronic medical conditions, and health-care workers.". The ECDC recommends vaccinating the elderly as the first priority, with secondary priority to people with chronic medical conditions, it also encourages vaccintation of healthcare workers.The CDC recommends every person 6 months and older to get annual flu vaccination except rare cases.Bigbaby23 (talk) 16:33, 25 December 2016 (UTC)
 * The WHO 2012 position is not a primary source.
 * The WHO recommends immunizing all people except those less than 6 months as does the CDC.
 * Both recommend particularly targeting specific groups.
 * Your proposal contains a lot of duplication and IMO is overly details. Those details belong in the body were they already are. Doc James  (talk · contribs · email) 08:55, 26 December 2016 (UTC)


 * I've described the 2012 WHO report about their own position as a primary source because we are having a conflict regarding interpretation of a fact which is not clear. As described in WP:PRIMARY
 * The WHO never states it like the CDC states it (which is not open or in need of interpretation). And as the above, I found out why.
 * Hence the use of secondary sources, specifically talking about our disagreement in interpetation.
 * I am adding another source (now 3) from 2016 "Available influenza vaccines: immunization strategies, history and new tools for fighting the disease" it says it methodologicaly under the section "Influenza vaccination recommendations" It has a whole sub section for each; WHO, CDC, ECDC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910442/
 * The WHO and ECDC have a similar strategy (Targeted) just with different priorities. The CDC has since 2010 a different strategy (Universal).Bigbaby23 (talk) 14:12, 26 December 2016 (UTC)
 * The source is fairly clear. It says "Annual vaccination (or re-vaccination, if the vaccine strains are identical) is recommended, particularly for high-risk groups."
 * This means it is recommended for other groups and even more recommended for high risk groups.
 * In Canada the recommendation is "Influenza vaccination is recommended for all individuals aged 6 months and older (noting product-specific age indications and contraindications), with particular focus on: people at high risk of influenza-related complications or hospitalization, including all pregnant women, people capable of transmitting influenza to those at high risk, and others listed in List 1." Doc James  (talk · contribs · email) 11:59, 27 December 2016 (UTC)


 * Look at how the WHO is summerizing their 2012 position on their on website http://www.who.int/influenza/vaccines/use/en/
 * Health Canada also switched to the universal strategy a few years back (Ontario was the first)
 * It is misleading to quote the WHO and CDC under one umbrella in this case.Bigbaby23 (talk) 14:22, 27 December 2016 (UTC)


 * James could you please interfere with Jytdog constant wikilawyering to get me banned and censored. He once again gone to  https://en.wikipedia.org/wiki/Wikipedia:Administrators%27_noticeboard/Edit_warring#User:Bigbaby23_reported_by_User:Jytdog_.28Result:_.29 Bigbaby23 (talk) 14:26, 27 December 2016 (UTC)

Yes this sums it up They say "Vaccination is especially important for people at higher risk of serious influenza complications, and for people who live with or care for high risk individuals." meaning that it is just not as important for people at lower risk. They than list the highest priority and the priority. It is not like it is not recommended in others. What do you think about "The World Health Organization also recommends yearly vaccination, especially in those at high risk" as a summary? Doc James (talk · contribs · email) 04:01, 28 December 2016 (UTC)
 * We have reliable secondary sources that do the Synthesis for us and explain it clearly. I've added templates to the article while we resolve this issue. See my new suggestion below:
 * The 2012 review by WHO is a reliable secondary source. Doc James  (talk · contribs · email) 06:36, 30 December 2016 (UTC)

Second draft
Vaccination against influenza is the most effective form of protection against the disease and is especially important for certain groups of people. The WHO and the ECDC recommend targeted vaccine programs, while the CDC and Health Canada recommend a univeral vaccine program. The World Health Organization recommends vaccinating pregnant women as the first priority, with secondary priority to risk groups; children aged 6–59 months, the elderly, people with specific chronic medical conditions, and health-care workers. The ECDC recommends vaccinating the elderly as the first priority, with secondary priority to people with chronic medical conditions, it also encourages vaccintation of healthcare workers. The CDC and Health Canada recommend every person 6 months and older to get annual flu vaccination except rare cases. The CDC targets vulnerable groups when vaccines supply are limited.

Bigbaby23 (talk) 06:29, 30 December 2016 (UTC)
 * I just emailed the WHO group that works on their influenza statement. They have confirmed that they recommend vaccinating all people over the age of 6 months and recommend vaccinating high risk groups more.
 * So this is a more accurate summary of their position "The World Health Organization also recommends yearly vaccination, especially in those at high risk."
 * All groups recommended even more so vaccinating those at high risk and thus the current wording is a better more concise summary. Doc James  (talk · contribs · email) 06:32, 30 December 2016 (UTC)


 * May I ask that you quote here what exactly you asked them (and thier answer if it's not breaking any privacy/copy edit policy)Bigbaby23 (talk) 07:47, 30 December 2016 (UTC)
 * The URL in ref #1 leads to a "link not found" page at WHO and I found nothing under "WHO 2015 systematic review of recommendations" when I searched that site and google as well. what is the ref? Jytdog (talk) 08:01, 30 December 2016 (UTC)
 * Fixed. Sorry about that. Bigbaby23 (talk) 08:18, 30 December 2016 (UTC)
 * Would be great if you used full citations. Refs above are formatted below.  The first ref is a book and needs a page number.   First ref is also specific targeted in location and level of development and should not be laid down next to the others without comment; apples and oranges.
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)
 * Jytdog (talk) 08:22, 30 December 2016 (UTC)

Third draft
Alright, I made an adjustment to the current paragraph by adding ECDC recommendation. I also removed any added wording not in the sources that may be accused of editorial pov or synthesis:

The World Health Organization recommends yearly vaccination, especially in those at high risk. The European Centre for Disease Prevention and Control recommends annual vaccination to risk groups. These groups include pregnant women, the elderly, children between six months and five years of age, those with other health problems and those who work in healthcare. The Centers for Disease Control and Prevention recommends all people over the age of 6 months without contraindications to get the vaccine yearly. Bigbaby23 (talk) 09:30, 30 December 2016 (UTC)
 * I disagree with these changes. Try a WP:RfC.
 * I asked "Does this statement "Annual vaccination (or re-vaccination, if the vaccine strains are identical) is recommended, particularly for high-risk groups." from the 2012 Influenza vaccine WHO article mean that all people are recommended vaccination with higher groups simply recommended to be vaccinated more?-- "
 * Answer "We're working on updating this recommendation at Who with gates funding so I'd expect an update soon. Otherwise you are more or less correct." Doc James  (talk · contribs · email) 06:19, 31 December 2016 (UTC)


 * Yes, but what are your reasons for disagreeing? We've got all major institutions recommendations. The WHO sentence is as you quoted it.Bigbaby23 (talk) 08:20, 31 December 2016 (UTC)

4th draft
How about:

"The World Health Organization and Centers for Disease Control and Prevention recommends yearly vaccination for nearly all people over the age of 6 months, especially in those at high risk. The European Centre for Disease Prevention and Control also recommends yearly vaccination of high risk groups. These groups include pregnant women, the elderly, children between six months and five years of age, those with other health problems and those who work in healthcare."

Doc James (talk · contribs · email) 05:14, 1 January 2017 (UTC)


 * James your insiststance of adding POV wording and WP:SYNTHESIS into a completely NPOV draft, and the fact that you are a Canadian Doctor (Health Canada = CDC recommendation), and a faculty member of BCU, which actively promotes the vaccine to everybody on campus. You are crossing the line into WP:ADVOCACY.Bigbaby23 (talk) 15:29, 1 January 2017 (UTC)
 * Page 14 of the WHO document says clearly: "Although influenza vaccination aims primarily at protecting vulnerable high risk groups against severe influenza-associated disease and death, influenza causes considerable morbidity worldwide even beyond these groups and therefore represents a public health problem with significant socioeconomic implications." It is clear that they advocate vaccinating everybody (except kids less than 6 months old) but take pains to identify high risk groups for countries with limited public health budgets.  There is no advocacy on the part of Doc James, that is clearly summary of the source. Jytdog (talk) 09:24, 2 January 2017 (UTC)
 * Bigbaby23 IMO the wording of the WHO source is fairly clear. I have contacted the group at WHO who wrote the recommendation and they are happy with my interpretation. If you want to change it try a RfC.
 * Yes I have a POV that matches that of mainstream medical opinion. Which is also by the way the POV that Wikipedia should match. Doc James  (talk · contribs · email) 12:21, 2 January 2017 (UTC)
 * I'm happy with James's draft. Bondegezou (talk) 14:21, 2 January 2017 (UTC)
 * A direct quote from Robb Butler, (World Health Organization technical officer in vaccine preventable diseases and immunizations in WHO Europe office) shows that the WHO position is similar to the European position and not the North American: "In a contrast to U.S. policy, the World Health Organization recommends only six "priority populations"...these six groups are nursing home residents, people with chronic medical conditions like asthma, the elderly, pregnant women, health care workers, and children from ages 6 months to 2 years, Butler said. They are more vulnerable to the severe effects of the flu or come into contact more often with this highly contagious virus. "We think the recommendations we have right now (are) a good start," Butler said. "Universal campaigns are quite challenging and expensive...We would need more evidence that more than these six key, target high-risk groups that are prioritized can benefit. "" http://edition.cnn.com/2013/01/17/health/flu-vaccine-policy/ Bigbaby23 (talk) 22:41, 3 January 2017 (UTC)


 * This is supported by other Secondary publications mentioned earlier:
 * ""In the US, the Advisory Committee on Immunization Practices recommends annual influenza vaccination for everyone 6mo or older if there are no medical contra-indications such as vaccine allergy [33]. The WHO recommends targeted vaccination against seasonal influenza for five priority groups viz. children aged 6mo to 5y, elderly persons aged 65y and above, persons with specific chronic illness, pregnant women, and healthcare professionals [3]"
 * And in a 2016 study, under the "Influenza vaccination recommendations" section:
 * We should actually lump the ECDC and WHO reccomendations together but I'm ok with the Third Draft Bigbaby23 (talk) 23:25, 3 January 2017 (UTC)
 * We should actually lump the ECDC and WHO reccomendations together but I'm ok with the Third Draft Bigbaby23 (talk) 23:25, 3 January 2017 (UTC)
 * We should actually lump the ECDC and WHO reccomendations together but I'm ok with the Third Draft Bigbaby23 (talk) 23:25, 3 January 2017 (UTC)


 * And James, why don't you email them a much clearer question, something like: "The CDC recommends a Universal Immunization policy while the ECDC a Targeted one. Is the WHO recommendation targeted or universal?, since it is not clear from the 2012 position paper"Bigbaby23 (talk) 23:38, 3 January 2017 (UTC)
 * We are not using CNN. Doc James  (talk · contribs · email) 11:32, 4 January 2017 (UTC)

RfC about Vaccination Recommendations, Efficacy summary and Criticism
A. In Regards to consensus.org/wiki/Talk:Influenza_vaccine#Lead_recommendation_summary Lead recommendation summary talk page discussions and proposals, Should it be Draft #3 or Draft #4 Of the three drafts; #2, #3 and #4 which one of them fulfills WP:NPOV and WP:VERIFY the most and thus should be used?

B. In regards to Evidence of poor quality talk page discussion, Do the suggested highlighted additions have WP:DUE?

C. In regards to Criticism in the talk page, are those two paragraphs acceptable? Bigbaby23 (talk) 06:33, 4 January 2017 (UTC)

Survey

 * A. I don't think Draft 3 is terrible, but I prefer Draft 4. Reads better, more succinct, good summary of what RS say.
 * C. I think the additions are undue and not consistent with WP:MEDRS. I would not object to covering some of this content in another way, drawing more on the scientific literature. Bondegezou (talk) 10:13, 4 January 2017 (UTC)
 * Support draft 4 but what we have right now is not that bad either. The suggested additions to the lead regarding poor quality data are undue weight as we already comment on the poor quality of data. Doc James  (talk · contribs · email) 11:33, 4 January 2017 (UTC)
 * A I'm leaning to Draft #2, but willing to settle on Draft #3. Draft #4 is in conflict with multiple secondary sources. And is a North American view edit violating NPOV and SYNTH.
 * B The additions have due weight; they are quoted for lack of quality research in certain groups that cannot reach a conclusion. And they also specifically go out of their way to state that the overall body of research for all groups is poor.
 * C the leading voices in Meta analysis of the flu vaccine are criticizing the actions of the policy makers. Off course it is relevant and DUE.Bigbaby23 (talk) 14:34, 4 January 2017 (UTC)


 * What a vague and horrible RfC to respond to. From what I think is being asked the answers are (A) Draft #4; (B) no, undue; (C) certainly undue in the lede. Alexbrn (talk) 15:00, 4 January 2017 (UTC)


 * A draft 4; B undue, C undue. Jytdog (talk) 15:12, 4 January 2017 (UTC)

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Drug Box
Tried to add vaccine type to drug box:

"vaccine_type = inactivated, attenuated"

doesn't work.

Peaceandlonglife (talk) 06:12, 2 May 2017 (UTC)

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Addition of Misperceptions Section
I think the influenza vaccine page would benefit significantly from the addition of a section discussing/debunking pervasive myths surrounding influenza vaccination. Many of these myths/misperceptions are commonly encountered in clinical practice and should be addressed. I'll start the section soon. It's imperative we get this information out there (I'm surprised it's not on the page already, TBH) and ensure it's well-sourced. I invite others to add content and add/suggest sources as well. Thanks! TylerDurden8823 (talk) 03:54, 26 September 2017 (UTC)

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Additional benefit of vaccination; reduction in incidence of resistent antibiotic microbes
Vaccines may help prevent the development of antibiotic resistance. By greatly reducing severity of influenza attacks, vaccine programs also reduce the cases with serious complications including secondary infections requiring the use of antibiotics. Reduced necessity for use of antibiotics may reducing over time the prevalence of infections resistant penicillin or other first-line antibiotics.

https://www.nature.com/articles/d41586-017-01711-6 Nature

Vaccines promoted as key to stamping out drug-resistant microbes "Immunization can stop resistant infections before they get started, say scientists from industry and academia."] Nature 19 July 2017

https://www.nature.com/articles/d41586-017-01711-6 Vaccines promoted as key to stamping out drug-resistant microbes "Immunization can stop resistant infections before they get started, say scientists from industry and academia." Nature 19 July 2017


 * Even vaccines against viral diseases, such as influenza, can help to prevent overuse of antibiotics. Many antibiotics are prescribed to treat opportunistic bacterial infections that occur in people weakened by flu — and a flu vaccine can lessen the chances of these infections occurring. Nicolas Van de Velde, the director of global health economics at GSK, told the meeting about an unpublished 2011–14 trial of one of his firm’s influenza vaccines in Europe, in which children who were vaccinated but caught flu anyway had such mild cases that use of antibiotics against other infections was halved.


 * I'm not sure the source meets WP:MEDRS, it looks like a news article, which is not a great source for medical facts, if a better source can be found then go ahead and add this to the effectiveness section. Tornado chaser (talk) 18:09, 23 July 2017 (UTC)


 * About Nature; I meant to cite Nature, which is a medical source, not a general news source.
 * That would be better. Tornado chaser (talk) 22:11, 24 December 2017 (UTC)

Three Cochrane updates on the influenza vaccine
Hello, Cochrane released three updates last week. Healthy adults: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub6/abstract Healthy children: http://onlinelibrary.wiley.com/wol1/doi/10.1002/14651858.CD004879.pub5/abstract Elderly: http://onlinelibrary.wiley.com/wol1/doi/10.1002/14651858.CD004876.pub4/abstract I am interested in hearing your feedback and suggestions on how we can present this evidence in the article. Thanks, JenOttawa (talk) 16:04, 5 February 2018 (UTC)
 * since they are very good references and are newer than anything currently in the article, would be best to insert into text as they'll make for a stronger 'reference base'...IMO--Ozzie10aaaa (talk) 11:20, 15 February 2018 (UTC)

Cost
We generally discuss the cost of stuff under society and culture per WP:MEDMOS. Cost is not often taken into account at the point of care. Doc James (talk · contribs · email) 03:03, 28 September 2018 (UTC)


 * That is fine, I moved the criticism to a sub-subsection under effectiveness as the criticism was all criticism of effectiveness. Tornado chaser (talk) 03:05, 28 September 2018 (UTC)

Very inconsistent stats
In our current version of the article, a CDC table of "U.S. vaccine effectiveness by start year" shows numbers in the range 10%-60%, averaging 41%.

A few paragraphs later, citing Cochrane, our Adults section says: "In unvaccinated adults, 16% get symptoms similar to the flu, while about 10% of vaccinated adults do. Vaccination decreased confirmed cases of influenza from about 2.4% to 1.1%." Simplistically, these proportions would suggest effectiveness rates around (16–10)/16 = 38% or (2.4–1.1)/2.4 = 54%, reasonably consistent with the CDC statistics.

Those results are all substantially weaker than the claim that introduces the Medical Uses section: "A 2012 meta-analysis found that flu vaccination was effective 67 percent of the time ." Based on the rest of the paragraph (76%, 70%, 66%), I doubt this is referring carelessly to "Efficacy of TIV was shown in eight (67%) of the 12 seasons analysed" from the citation's abstract – but the full Lancet reference for the claim is not freely accessible online. Can anyone with Lancet access explain briefly why its 67% would turn out so much higher than the other estimates of vaccine effectiveness? Did CDC find an average effectiveness of just 41% because its sample or methodology was so very different or biased? Did Lancet measure effectiveness in a substantially different way, or were there heavy "adjustments" that our article hasn't made clear? Thanks if anyone can clarify such a large numerical discrepancy in the article. —173.68.139.31 (talk) 11:28, 12 January 2019 (UTC)


 * One issue is that vaccine effectiveness varies from year to year depending on what strains are prevalent in the population and what strains were picked for the vaccine. Here are some additional links: European Centre for Disease Prevention and Control; Osterholm et al., 2012. Bondegezou (talk) 12:55, 12 January 2019 (UTC)


 * Thanks for the quick reply. ECDC's results seem to be very similar to CDC's: Flu vaccine effectiveness peaks at 60% in the best year, and averages somewhere in the 40s. Osterholm's "67%" paper is the same one from Lancet, still not freely available. Might his study be benchmarked to a sample that includes lots of children, for whom vaccine effectiveness is higher? —173.68.139.31 (talk) 18:33, 12 January 2019 (UTC)

WHO vs. CDC recommendations?
The current version includes this change, but it doesn't seem to me that the referenced quote means what is inferred by the change: "Annual vaccination  (or  re-vaccination,  if  the  vaccine  strains  are  identical)  is  recommended,  particularly  for  high-risk  groups."; this sounds like it's simply recommending that the vaccination programme be annual, not that it's recommending vaccination for nearly all people. I can't seem to find anything from WHO which clearly recommends this. Maxdamantus (talk) 04:08, 16 June 2019 (UTC)
 * I think you were the one introducing the WHO reference in the text. Despite searching, I wasn't able to find convincing evidence that WHO makes such a strong recommendation (but I may well be overlooking it in the document). You refer to an RfC in your edit summary, where is this RfC, could you link to it? There may be more background information for me to digest. Thanks. effeietsanders 06:00, 4 October 2019 (UTC)
 * https://en.wikipedia.org/wiki/Talk:Influenza_vaccine/Archive_3#Lead_recommendation_summaryBigbaby23 (talk) 02:02, 5 October 2019 (UTC)

The WHO recommendations in the article don't appear to agree with the older provided citation or with more recent sources at https://www.who.int/en/news-room/fact-sheets/detail/influenza-(seasonal) and http://www.euro.who.int/__data/assets/pdf_file/0004/317344/Methods-assessing-influenza-vaccination-coverage-target-groups.pdf

WHO recommends annual vaccination for: pregnant women at any stage of pregnancy

children aged between 6 months to 5 years

elderly individuals (aged more than 65 years)

individuals with chronic medical conditions

health-care workers. Whywhenwhohow (talk) 06:03, 14 October 2019 (UTC)

There is more clarification and detail in the "Recommendations" section. Whywhenwhohow (talk) 06:26, 14 October 2019 (UTC)

merge proposal for specific vaccines
See Talk:Fluzone for a proposal to merge Influvac, Optaflu, Fluzone together into Influenza vaccine brands (and make it easy to add other specific brands such as Vaxigrip as separate sections rather than redirects or new articles). Please centralise discussion over there. Boud (talk) 22:08, 5 December 2019 (UTC)

Oral Influenza Vaccine in Trials
, this is not considered a secondary source as defined in WP:MEDRS and is not suitable for inclusion. It's too early to include this. Numerous promising treatments in the clinical trial phase do not pan out. If it were phase III and in a prominent journal (e.g., New England Journal of Medicine), I could perhaps understand the rationale for including it (perhaps in a Research section). When you say it's being covered in a secondary source-do you have a well-respected peer-reviewed review journal article that covers this specific oral influenza vaccine? Or a tertiary reference like a textbook? This seems like you are edit warring the material in and not being respectful of WP:BRD-why? (yes, I know it's optional but it really is the accepted guidance on Wikipedia for the right thing to do-this is well-established).

Additionally, what is discussed in the lead should also be covered in the body of the article and should be highly noteworthy (this is not yet noteworthy enough to merit inclusion in the lead-as above, it's premature at this time since many experimental treatments in phase II clinical trials fail). I will see what the community thinks for broader consensus and further discussion. TylerDurden8823 (talk) 18:37, 26 January 2020 (UTC)
 * I'm not sure I agree, but I'll remove it anyways. Thanks for the thorough explanation. Daniel.Cardenas (talk) 18:48, 26 January 2020 (UTC)
 * If not, you're welcome to explain why it belongs. Otherwise, it should be removed. TylerDurden8823 (talk) 18:56, 26 January 2020 (UTC)
 * Is there a precedent for phase 2 working better than existing treatments and not launching? Daniel.Cardenas (talk) 18:59, 26 January 2020 (UTC)
 * No, phase 2 trials have a high rate (~82%) of failure. If it survives additional, larger and much more expensive phase 2 trials, as a vaccine, it will need to clearly demonstrate safety and efficacy in tens of thousands of people with flu. Without a major pharma partner (none displayed, here -- this was my error, as Janssen is a partner for the oral vaccine; see below), and with a share price of 49 cents, it does not appear Vaxart has the finances to take this project much further (~ $22M/yr in losses). --Zefr (talk) 19:13, 26 January 2020 (UTC)
 * Note: I missed mention of the Janssen partnership on developing the oral vaccine, shown in the table footnotes on p 6 of the Vaxart investor file. It was also discussed in the SeekingAlpha article dated July 2019. --Zefr (talk) 03:54, 27 January 2020 (UTC)
 * If we included information about this, it would belong in the ==Research== section (not the lead), and it would be a pretty bland statement that says there's some research on flu vaccines that can be delivered as a pill.  could be cited for that.  MEDRS has a strong preference for secondary sources, although WP:MEDPRI does permit primary sources under limited circumstances, as a temporary measure.  Alternatively, and more usually, we could just wait a few months.  It seems likely that this will get mentioned in a secondary source before long.
 * I also want to say that while a flu vaccine in pill form could be more pleasant for the patients who are currently getting a flu jab every year (e.g., me), a vaccine that could bypass the Cold chain problem and had no risk of spreading bloodborne infections is an important area of research. WhatamIdoing (talk) 21:41, 26 January 2020 (UTC)
 * Someone did try to put it in ==Research== and mentioning, but it was removed by Zefr. While I agree the removed edit sounds like advert but if we just paraphrase that edit and remove advert part... then I think it'll be OK. Ckfasdf (talk) 01:17, 27 January 2020 (UTC)
 * Would go in the research section if anything. Would like to see a review on the topic not a press release. Doc James  (talk · contribs · email) 01:53, 27 January 2020 (UTC)
 * OK, i have included it on research section. other reviews on the topic is scarce at the moment (afterall the publication is issued few days ago), but will update it once further review available. Ckfasdf (talk) 02:56, 27 January 2020 (UTC)
 * There's a review from 2008 by someone from that company, but I haven't found much else at PubMed. Google Scholar has a few more hits.  WhatamIdoing (talk) 03:59, 27 January 2020 (UTC)

Remove quadrivalent flu in the research section
IMO Research section is only for vaccine in research and development phase. Since quadrivalent flu vaccines (injection or nasal) are already in the market or already past research phase. Can we remove "Quadrivalent vaccines for seasonal flu' sub-section in the Research section? and move the content elsewhere in the article. Ckfasdf (talk) 01:07, 19 February 2020 (UTC)

Request edit - 6 of 7 M-001 trials completed. Only one of the 7 trials has results. None that BiondVax sponsored do.
>"As of 2019, there were some ongoing clinical trials of the M-001[219] universal influenza vaccine candidate[220][136][221][222]" needs updating. The trial NCT03058692 has results, and 5 of the other 6 have completed. NCT02691130: results failed NLM's limited QC review - twice. None of BiondVax's 6 completed trials have published results. NCT01419925: results also failed NLM's limited QC review - three times. BiondVax's failed to submit the legally required "basic results" for a single one of its M-001 trials.

This could be, and I ask it be noted with, "As of May of 2020, 6 of 7 M-001 trials are completed. One of the 7 trials has results. None that BiondVax sponsored do."

As for NCT03058692, the results are new, very long (about 67 p-values) and there's no summary or conclusion; I'm not sure what edit about that is appropriate. Expert help needed.--50.201.195.170 (talk) 07:37, 2 May 2020 (UTC)


 * The IP editor has not declared a conflict of interest, or there is not one I can see. If this is a COI edit request, the propoer disclosures need to be made. Spintendo  10:03, 2 May 2020 (UTC)
 * This is editor interpretation of preliminary, primary research. I don't see how we can include this new data without reporting from reliable secondary sources. In lieu of such reporting, perhaps we could just delete the sentence in question? Global Cerebral Ischemia (talk) 13:52, 2 May 2020 (UTC)
 * I've no conflict of interest to disclose. I don't recall why I only made a request.  My proposed text is certainly not LESS appropriate than the out-of-date text I urged be edited.  My text summarizes PubMed's reporting of result status; it does not, at all, interpret the findings of preliminary, primary research.  I don't recall MEDRS addressing trial result status in general or from the NLM specifically, but when it comes to result status, it's clearly not the case that the WP:V policy is an issue.  GCI, Spintendo, do you have a conflict of interest?--50.201.195.170 (talk) 01:37, 25 May 2020 (UTC)

Why the extra detail on US and EU vaccines?
I moved some detail that was tagged onto the end of the "Annual reformulation" section that seemed to be re-stating the same years, but just for the US and EU recommendations, upwards to group them all chronologically. To me they all look pretty much like the WHO recommendations - surely the article doesn't need all of this extra list detail? Laterthanyouthink (talk) 09:35, 29 April 2021 (UTC)

Timing question
Hi, this article says ``The intradermal vaccine was not available during the 2018–2019 and 2019–2020 influenza seasons.[14][20][21][22]`` -- why not? Tried reading the sources but they're rather confusing. Could you please check? Thanks Gryllida (talk, e-mail) 11:05, 5 September 2021 (UTC)

Quadrivalent vaccine
The article is missing an explanation, what is the Quadrivalent vaccine. If a user searches Wikipedia there is a redirect, back to this paragraph. Juandev (talk) 08:10, 23 November 2021 (UTC)

"Flu jabs" or "flu shots"?
As many north american editors may point out: what is a flu jab?

The term "shot" is not used in the UK (commonwealth) in the context of vaccines therefore in order to make the page more accessible to all of those speaking Commonwealth English now both versions are included.

This edit as been long debated between me and user Retimuko on his talk page here, please have a read before making any edits to this.

Thanks, Fra098 (talk) 23:31, 29 November 2021 (UTC)
 * Left the terms but removed the explanation, which makes no sense. There is no such variety as "Commonwealth English". Flu shot is the most common term in North America and flu jab in the UK, but those aren't the only varieties of English that use those terms.  Pepper Beast    (talk)  04:08, 30 November 2021 (UTC)