One of the many myths of the vaccine denialism movement is that healthcare workers will quit if there is a mandatory vaccination, usually the flu. Many of the healthcare worker vaccine deniers base their opposition to vaccines based on thoroughly debunked lies about vaccinations. Their invented opposition to vaccines is in direction contradiction to their obligation to protect the health of patients. However, more and more healthcare systems are mandating the flu vaccine for their employees.
A four-year analysis of mandatory influenza (flu) vaccinations, which are a condition of employment at Loyola University Health System in Chicago, IL, showed no statistical increase in voluntary terminations of employees. In the first year of Loyola’s mandatory policy (2009-10 flu season), 99.2% of employees received the vaccine, 0.7% (yes, 0.7%) were exempted for religious/medical reasons, and 0.1% refused vaccination and chose to terminate employment with Loyola. In 2012, the last year of the study, the vaccination uptake rate at Loyola remained steady: 98.7% were vaccinated, 1.2% were exempted and 0.06% refused vaccination.
According to Dr. Jorge Parada, study author and professor of medicine at Loyola University Chicago Stritch School of Medicine, reported that ”in reality our numbers were even better than that, of the 5 persons who refused vaccination in the mandatory period, 3 were unpaid volunteers, who later reconsidered, received vaccine and returned to Loyola. The two other persons were part-time staff, each with only 10% time commitment at Loyola…truly reflecting a 0.002 vaccine refusal rate” reports Parada. The study showed that, over the course of four years, less than 15 staff, including volunteers, out of approximately 8,000 healthcare workers in the system, chose termination over vaccination. Loyola has sustained a 99 percent compliance average since adopting the mandatory flu vaccination protocol four years ago.
(more…) «Mandatory flu vaccinations cause healthcare…»
A recent article published in a leading psychiatry journal, JAMA Psychiatry, has shown that pregnant mothers’ exposure to the influenza (flu) was associated with a nearly 4X increase in risk to their child eventually developing bipolar disorder in adulthood. These findings add to mounting evidence of possible shared underlying causes and illness processes with schizophrenia, which some studies have also linked to prenatal exposure to influenza. Bipolar disorder, historically called manic depressive disorder, is a mood disorder where the sufferer can experience episodes of a frenzied state known as mania (or hypomania), typically alternating with episodes of depression. It can be treated with medications and psychotherapy (especially cognitive therapy), but more difficult cases require the individual to be voluntarily or involuntarily institutionalized until the mood changes can be reduced or eliminated.
One of the arguments made by vaccine denialists is that vaccines cause significant increases in nervous disorders, and they point to the vaccine’s Package Insert (PI) as “proof”. Setting aside the misuse of the information in a PI, there seemed to be some evidence that there was a slight increase in the rates of Guillain-Barré syndrome (GBS) following vaccinations, although the risk was far outweighed by the benefit of preventing deadly diseases. Guillain-Barré syndrome is an autoimmune disorder of the peripheral nervous system, where the immune system appears to attack nerves involved in movement, although sometimes it attacks respiration and other functions. Guillain-Barré syndrome is usually preceded by a viral or bacterial infection, such as the flu. It is a serious condition, which often takes several months for full recovery. About 80% of those who contract the disorder recover fully with treatment.
(more…) «No link between vaccines and…»
The 2012-2013 flu season is beginning to wind down from a moderately severe season. Sadly, according to the CDC, 105 children died this season from the flu. And a preliminary review of the data by the CDC found that 90% of those children who died were not vaccinated for this season’s flu. In case that wasn’t clear, over 90 children died from influenza, a vaccine-preventable disease.
This review by the CDC indicated that 60 percent of deaths occurred in children who were at high risk of developing serious flu-related complications, but 40 percent of the children, who had died, had no recognized chronic health problems. The proportions of pediatric deaths occurring in children who were unvaccinated and those who had high-risk conditions are similar to what the CDC has observed in previous flu seasons.
Earlier this flu season, the CDC had strongly recommended that children get the flu vaccine, and those who had never been vaccinated for the flu before, get two doses of the vaccine. And despite the various myths about the flu vaccine, it is extremely effective, it will not give a child the flu, and it has an incredibly high safety profile.
Many of us who discuss medicine know that every medical procedure involves a risk and a benefit. With the flu vaccine, there are few risks, and even those are minor. But the benefit is immense for children. Saving lives. And in my view of the world, saving even one life, one child, is worth it. Parents who don’t give the flu vaccine to their children put them at a small, but significant risk of severe complications to the flu, up to and including death. Maybe next year someone will read this article, and think, “I want to save my child’s life.” I can only hope.
- Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)–United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep. 2012 Aug 17;61(32):613-8. PubMed PMID: 22895385.
- Centers for Disease Control and Prevention. CDC Reports About 90 Percent of Children Who Died From Flu This Season Not Vaccinated. March 22, 2013.
The H1N1 influenza pandemic of 2009 was the second pandemic in recent history that resulted from the H1N1 influenza virus, also known as the swine flu. The first one, known as the 1918 flu pandemic, killed over 50 million people, or about 1-3% of the world’s population at the time. The 2009 pandemic, though not as serious as the one in 1918, probably killed over 500 thousand people worldwide. In the United States, the CDC estimated that between 43 and 89 million people were infected with the 2009 H1N1 flu. They also estimated that of those, about 200-400 thousand were hospitalized, and approximately 12,470 died. The only reason the pandemic wasn’t worse was probably as a result of an effective H1N1 vaccine along with a broad effort to vaccinate those at highest risk of complications.
Along with the vaccination program, comprehensive safety surveillance was initiated to monitor for adverse events. This program identified a small increase in Guillain-Barré syndrome following the H1N1 vaccination. In paper published this week, researchers did a meta-analysis of the data from the monitoring program to quantify the level of risk.
(more…) «Slight risk of Guillain-Barré syndrome…»
Today, the British Medical Journal published a retrospective study, by Elizabeth Miller, that analyzes the risk of narcolepsy in children and adolescents in England who received the 2009 A/H1N1 pandemic flu vaccine (Pandemrix) from October 2009 through mid-2010. This study followed up on the observations seen in Finland and other countries that there was some increased risk of narcolepsy in children a few months after receiving the vaccine.
As background, narcolepsy is a chronic neurological disorder caused by the brain’s inability to regulate sleep-wake cycles normally. Individuals with narcolepsy often experience daytime sleep patterns, but the disorder should not be confused with insomnia. It is not caused by a mental illness or psychological problems. It is most likely affected by a number of genetic mutations and abnormalities that affect specific biologic factors in the brain, combined with an environmental trigger during the brain’s development, such as a virus. It may also be a result of an autoimmune disorder. At this time, there is no cure for narcolepsy, but it can be successfully treated by medications and other therapies.
Roughly 70% of individuals who have narcolepsy have a comorbidity of cataplexy, a sudden and transient episode of loss of muscle tone, often triggered by strong emotions.
(more…) «Pandemic flu vaccine and narcolepsy–an…»
This week, the Centers for Disease Control and Prevention (CDC) issued an interim report on the effectiveness of this season’s flu vaccine in the United States. Because these reports will be cherry picked for data by vaccine denialists (and may cause vaccine supporters to worry about their support of this particular vaccine), I want to look at the data carefully, and make sure we understand what is exactly reported.
According to the CDC, this year’s flu season is pretty serious in the USA. Current data, shows that about 4.6% of patient visits to health care providers are for influenza like illnesses (ILI). Thirty states and New York City are now reporting high ILI activity; an increase from 24 states last week. Additionally, 10 states are reporting moderate levels of ILI activity. Forty-eight states reported widespread geographic influenza activity for the week of January 6-12, 2013. This increased from 47 states in the previous week.
Although there has been a slight drop-off in ILI visits over the past couple of weeks since the peak in early January, the CDC continues to identify this season as a “moderately severe” one, and supplies in some areas have tight supplies of the flu vaccine.
(more…) «Tamiflu-does it work»
The CDC is reporting that influenza activity continues to increase in the United States and most of the country is now observing high levels of influenza-like-illness (ILI). ILI reports are approaching levels that usually seen during moderately severe flu seasons. Of course, the CDC continues to recommend vaccinations for the flu, and antiviral treatment if appropriate.
According to Dr. Joe Bresee, Chief of the Epidemiology and Prevention Branch in CDC’s Influenza Division, “While we can’t say for certain how severe this season will be, we can say that a lot of people are getting sick with influenza and we are getting reports of severe illness and hospitalizations. Anyone who has not already been vaccinated should do so now. And it’s important to remember that people who have severe influenza illness, or who are at high risk of serious influenza-related complications, should get treated with influenza antiviral medications if they get flu symptoms regardless of whether or not they got vaccinated. Also, you don’t need to wait for a positive laboratory test to start taking antivirals.”
(more…) «The 2012-13 flu season getting…»
Yesterday, I wrote about the CDC reports regarding pediatric deaths from the flu. Those were just numbers, but there are real kids and real parents of those kids who constitute those numbers.
The Maine Public Broadcasting Network (MPBN) reported about the death of an elementary school child from the flu. The child was healthy, so it wasn’t that the flu increased some risk factor because of an underlying disease.
According to Maine’s CDC Director, Dr. Sheila Pinette, pediatric flu deaths are not common in the state. She stated that flu can be fatal in people who are elderly or have a compromised health status, but this elementary school child was believed to be healthy. Dr. Pinette wants everyone to get vaccinated against the flu, unless the vaccine is medically contraindicated (which is very very rare). According to the MPBN article, “that’s an expansion from previous CDC recommendations that focused on the young, the elderly, and health care workers.”
(more…) «A child dies from the…»
If you have any reluctance about having your children receive their annual flu vaccination, look at the chart below:
Children die from the flu virus–282 innocent children died from the flu in 2009-10, 122 in 2010-11, 34 in 2011-12. So far this flu season, 6 children have died. The number varies from highs during pandemic years, such as in 2009-10, and lower in non-pandemic years.
The CDC predicts that 2012-13 could be serious, and the current flu vaccine protects against 3 subtypes of the seasonal flu in North America:
- A/California/7/2009 (H1N1)-like
- A/Victoria/361/2011 (H3N2)-like
There are no valid excuses for avoiding a flu vaccination. Just in case you believe the myths about the flu vaccine, they’re not true. The vaccine does not itself cause the flu. The vaccine is safe for pregnant women. And most of the other myths have been solidly debunked.
Get a flu vaccination for your kids. Because Vaccines Save Lives.
- Centers for Disease Control and Prevention. 2012-2013 Influenza Season Week 49 ending December 8, 2012.
- Centers for Disease Control and Prevention. Final estimates for 2009–10 Seasonal Influenza and Influenza A (H1N1) 2009 Monovalent Vaccination Coverage – United States, August 2009 through May, 2010.
- Centers for Disease Control and Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)–United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep. 2012 Aug 17;61(32):613-8. PubMed PMID: 22895385.
- Centers for Disease Control and Prevention (CDC). Misconceptions about Seasonal Influenza and Influenza Vaccines.
Autism Spectrum Disorders (ASD) appear to be an increasing medical issue in the United States. According to the Centers for Disease Control and Prevention, ASD is diagnosed in approximately 1 in 88 children, and are reported to occur in all racial, ethnic, and socioeconomic groups. ASD refers to a broad range of symptoms, from mild social awkwardness to mental retardation, repetitive behaviors and an inability to communicate. The CDC states that diagnosing ASD can be difficult, because there are no medical tests, such as a genetic or blood test, that can provide a definitive diagnosis. Physicians make a diagnosis through observation of a child’s behavior and development.
Medical science agrees that the increase in diagnosis is not only a result of better diagnostic standards, but also because there appears to be more children who are actually developing autism. Unfortunately, science has not uncovered the cause. Genetics are a critical factor, for example, since it has been shown that if one twin has autism there is a high likelihood that the other twin will also develop ASD. But are there other factors?
A couple of days ago I reported that the flu vaccination not only prevents the flu itself, but it may also reduce risk of certain types of heart disease and death from cardiovascular events. In another study presented at the Canadian Cardiovascular Congress meeting in Toronto, the authors stated that the flu vaccination may have a critical benefit to patients who have implantable cardiac defibrillators (ICD), a small battery-powered device that automatically detects cardiac arrhythmias, then corrects it by delivering an electrical shock that can revert ventricular fibrillation, and that has been extended to include both atrial and ventricular arrhythmias.
According to study author Dr. Ramanan Kumareswaran, physicians have known that patients tend to need more ICD shocks during flu season, and wanted to investigate ways of reducing this need to rely on the device.
The study surveyed 229 patients who had come in for appointments related to their ICD care from September through November 2011. Of those patients, 179 (78%) reported that they had received the influenza vaccination in the previous year. Patients who received the influenza vaccine were older than those who did not (70.8 vs. 64.8 years, P=0.0005). Finally, there was no difference in the prevalence of coronary artery disease, diabetes, renal disease, and prior stroke in patients the vaccinated and un vaccinated patients.
Some of the results of the survey were:
- Patients who received the flu vaccine were more likely to reject statements such as, “The Flu shot is not effective” and “The Flu shot will make me sick” compared to individuals not receiving the influenza vaccine.
- Vaccinated individuals also planned to obtain the influenza vaccine in the upcoming year.
- Thirty nine (17.0%) individuals in the overall cohort received at least one ICD therapy during the two pre-defined periods – 10.6% who received the influenza vaccine received at least 1 ICD therapy during influenza season compared to 13.7% who did NOT receive the influenza vaccine (P=NS).
- About 13.7% of the unvaccinated patients experienced at least one ICD therapy (meaning that the ICD device had to adjust the heart rate) during the flu season compared to the 10.6% of patients who were vaccinated. This wasn’t a significant difference. However, the average number of ICD therapies per person during influenza season was greater in individuals not receiving the influenza vaccination (0.45 therapies) compared to individuals who did receive the influenza (0.14 therapies).
“What is interesting is that if this is consistent over time, it could be of significant benefit to our patient population who already have compromised survival to start with,” wrote Dr. Sheldon Singh, one of the study’s authors.
The authors concluded:
A large proportion of patients with ICDs receive the influenza vaccine. Receipt of the influenza vaccine may be associated with a reduction in ICD therapies during influenza season.
Now, as I’ve said with the other study, from the same Canadian Cardiovascular Congress meeting, that showed that a link between getting the flu vaccination and reduced cardiovascular events, these studies are not peer reviewed. They aren’t published yet in journals. They haven’t been repeated by other researchers. But the study seems to be sound, and it is a very sound argument for getting the flu vaccination if you have serious cardiovascular issues.
Vaccines save lives.
- R. Kumareswaran, R. de Souza, M. Khurana, E. Crystal, S. Singh. 150 The Use of the Influenza Vaccine in Patients With Implantable Cardiac Defibrillators. Canadian Journal of Cardiology, Volume 28, Issue 5, Supplement , Pages S146-S147, September 2012. doi:10.1016/j.cjca.2012.07.154
- J.A. Udell, M.E. Farkouh, D.L. Bhatt, C.P. Cannon. 187 Influenza Vaccination and Reduction of Cardiovascular Events-A Systematic Review and Meta-Analysis. Canadian Journal of Cardiology, Volume 28, Issue 5, Supplement , Page S161, September 2012. doi:10.1016/j.cjca.2012.07.187
In addition to preventing the disease, the flu vaccination may have a more important benefit to those who get the shot. Dr. Jacob Udell, a cardiologist at Women’s College Hospital and the University of Toronto, looked at published clinical trials on flu vaccinations, dating back to the 1960s, examining the vaccine’s effect on cardiovascular events. Dr. Udell presented his meta-review results at the 2012 Canadian Cardiovascular Congress on October 28 2012.
The combined studies examined a total of 3227 patients, with an equal split between patients with and without heart disease. Half of the patients were randomly assigned to receive flu vaccine, and those that did not received a placebo. Four randomized controlled trials of moderate quality conducted between 1994-2008 met inclusion criteria. Here are some of the most important results:
- An approximate 50 per cent reduction in the risk of a major cardiac event (heart attack, stroke, or cardiac death) compared with placebo after one year of follow-up.
- A similar trend was seen for the flu vaccine reducing death from any cause (approximately 40 per cent).
- The influenza vaccine reduced cardiovascular events and cardiovascular death in people with or without heart disease.
Influenza vaccine reduced non-fatal CV events and may reduce sudden CV death in patients with and without CVD. However, the very low number of observed CV events and important design limitations among these RCTs strongly limit their validity and make it challenging to draw a definitive conclusion. A large, adequately powered, international multicenter RCT testing the efficacy of influenza vaccine to reduce incident and recurrent CV events is prudent to confirm these findings.
According to a report by Jennifer Nelson at NBC News, “The flu vaccine could be an important way to maintain heart health and ward off strokes and heart attacks, the researchers said.” Nelson also quoted Dr. Udell as proclaiming that “perhaps that the flu vaccine is a heart vaccine.” Well, maybe that’s overstating the case, but who knows.
But why would the flu vaccine reduce cardiovascular events? Nelson’s report suggested a couple of very plausible reasons:
- “Udell said it may be that when people develop heart disease, some factor ’tips them over the edge,’ such as plaque clogging arteries, or lower levels of oxygen as a result of the flu.” This is entirely possible, since those with atherosclerosis do have reduced blood flow to heart muscle. And the flu, being much more dangerous than most people believe, could just push someone over the line from having just enough oxygen for their heart muscle, to not enough.
- “Dr. Sarah Samaan, a cardiologist and director of the Women’s Cardiovascular Institute at Baylor Heart Hospital in Plano, Texas, said the key to the link may be in reducing inflammation. When someone gets the flu, blood levels of inflammatory substances rise, and inflammation of the blood vessels can trigger heart attacks. ‘This happens because inflammation can make cholesterol plaques in the blood vessels unstable,’ Samaan explained. Unstable plaques are more likely to develop tiny cracks, which can cause blood clots to form. Such clots can block blood flow within arteries, causing a heart attack (if the blood vessel supplies the heart) or a stroke (if the artery feeds the brain), she said.” Again, entirely plausible.
Now, a couple of caveats about this study. First, it’s presented at a conference. Second, it’s not peer-reviewed. I’ll assume that it’s good work, but until it’s peer-reviewed and published in a great journal, it’s at the level of highly provocative. And it’s intensely interesting. But the great thing about meta-reviews is that they are easily repeated, and easily criticized if there’s a problem with the statistical analysis, so in light of that, I have high confidence in the quality of these results.
The 50% reduction in cardiovascular events is both clinically relevant, and may be higher than what will be seen in future randomized trials. But even if it’s 40%, 30%, or even 10%, that’s an amazing benefit of the flu vaccine for individuals at risk for cardiovascular events. The thing is that although a lot of people know that they are at risk, they have diabetes or are overweight, many people are unaware of their cardiovascular risks. They may have untreated hypertension. Or atrial fibrillations. Or any number of diseases where the risks of cardiovascular events are high, and can reduce the risk by a significant amount just by a simple and safe flu vaccination. And don’t listen to those myths about the flu vaccine, they just aren’t true. No, they aren’t true.
Vaccines save lives. And they might keep you from getting a heart attack!
- J.A. Udell, M.E. Farkouh, D.L. Bhatt, C.P. Cannon. 187 Influenza Vaccination and Reduction of Cardiovascular Events-A Systematic Review and Meta-Analysis. Canadian Journal of Cardiology, Volume 28, Issue 5, Supplement , Page S161, September 2012. doi:10.1016/j.cjca.2012.07.187.
- Nelson J. Flu vaccine may protect you from a heart attack. NBC News. October 28, 2012.
- Rowan K. 6 Flu Vaccine Myths. MyHealthNewsDaily.com. October 26, 2012.
It’s getting close to flu season, and it’s time to get your flu shot. Of course, there are myths for why people won’t get their flu shots. All of them are amusingly bad.
Last fall, Dr. Mark Crislip published A Budget of Dumb Asses (requires a Medscape account) that takes on anti-science with a whole new level of snark. I have part of it here for you, thanks to Biodork’s (great name) Time for your flu shot! It’s all about getting (or not getting) the flu vaccination, but you can replace flu with any other vaccination. Apparently, he wrote it for health care workers, but hey, I think it works for patients too!
Mark Crislip starts out his snark with a quick statement about not getting a flu shot. You might be a dumb ass, if you’re unwilling to get the vaccine:
I wonder if you are one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested), you may have had Guillain-Barre, in which case I will cut you some slack. But if you don’t have those conditions and you work in healthcare and you don’t get a vaccine for one of the following reasons, you are a Dumb Ass.
The Centers for Disease Control and Prevention recently published a comprehensive analysis of influenza vaccination rates of the US population during the 2011-2012 season. Mostly, the numbers continue to be disappointing, even in groups that should have higher rates of flu shots, such as pregnant women and healthcare workers. These numbers continue to demonstrate the difficulty in increasing the vaccine uptake rate in the US.
Public health officials has been pushing to increase the flu vaccination rates of healthcare workers. The numbers are somewhat disappointing, but as more states mandate flu vaccinations for healthcare workers, the rate may improve. The CDC found that about 63.4% of healthcare workers had been vaccinated for the flu as of November 2011, an 8 point improvement over 2010.
(more…) «Disappointing 2011 flu vaccination rates»
As part of my history in medical industry, I used to train sales representatives on new medical products and procedures. Because these sales reps were in hospitals and physicians offices, many medical companies (yes, Big Pharma), a condition of employment was that they were required to be up-to-date on their vaccinations including the seasonal flu vaccine. Not all companies did this, and not all companies made it mandatory, but there was nothing worse than having a large percentage of the sales force out of commission sick with flu, especially if a new product was being launched. And doctor’s offices did not want sales reps walking into their offices sick either, so it was a good business practice. Exemptions were just not given, because it was a job requirement stated clearly in the written job offer, so they had a choice to not take the job.
It was ironic that these well-paid, well-educated mouthpieces for Big Pharma would make up the most silly excuses for not wanting the flu vaccination. The number one reason, that I would hear, is that “the flu shot always gives me the flu.” And that’s just not these sales reps who would make up this claim, but apparently in a 2010 CDC poll, 62% of Americans also believe the flu vaccine can actually cause the flu.
Well, let’s just blow that myth right out of the water:
- According to the CDC, “No, a flu shot cannot cause flu illness. The viruses contained in flu shots are inactivated (killed), which means they cannot cause infection. Flu vaccine manufacturers kill the viruses used in the flu shot during the process of making vaccine, and batches of flu vaccine are tested to make sure they are safe.”
- In a 2000 study on flu vaccine effectiveness, 2.2% of vaccine recipients vs. 4.4% of placebo recipients had laboratory confirmed influenza illness in 1997-1998. During the next flu season, 1% of vaccine recipients and 10% of placebo recipients had influenza illness. So, the risk of getting the flu is much higher in the non-vaccinated group.
- According to the ACIP (Advisory Committee on Immunization Practices), rare symptoms include fever, muscle pain, and feelings of discomfort or weakness, which may mimic flu symptoms, but last only 1-2 days (as opposed to flu which may last 7-10 days).
So, if you think that the flu vaccine gives you the flu, it really doesn’t. And I’m not the only one saying this:
- Fact vs. Fiction – Families Fighting Flu
- Friday Flu Shot: Myth Busted by MOMmunization « Shot of Prevention
- Myth Buster | MOMmunizations
Get your flu shot. Because, you know, Vaccines Save Lives.
In 2009, the H1N1 flu pandemic was an influenza pandemic that was first described in April 2009. The virus appeared to be a new strain of H1N1, which was responsible for the 1918 flu pandemic, that arose from a triple reassortment of bird, swine and human flu viruses that then further combined with a Eurasian pig flu virus, leading to the term “swine flu” to be used for this pandemic. Unlike other strains of flu, H1N1 does not disproportionately infect older adults (greater than 60 years), which makes this a characteristic feature of this H1N1 pandemic, and made it especially dangerous to children. The CDC has reported some sobering worldwide statistics for the 2009 H1N1 pandemic, including that between 151,700 and 575,400 people perished worldwide from 2009 H1N1 virus infection during the first year the virus circulated.
(more…) «The importance of flu surveillance»
The Centers for Disease Control and Prevention (CDC) has just published a study in Pediatrics on the effects of influenza in children with neurologic disorders. It compared the outcomes, during and after the flu ,between kids with or without neurological disorders. The outcomes studied were deaths and hospitalizations during the H1N1 influenza pandemic, between April 15 and September 30, 2009, by looking at medical records of reported pediatric deaths.
(more…) «Flu vaccinations for children with…»