Catherina and Science Mom on Respectful Insolence

Yesterday, Orac blogged about a comment that Dr. Bob Sears made about us on his Vaccine Discussion Forum, entitled Weekly Disclaimer about SM and Catherina by Dr. Bob - posted on 8/17/2009 and here it is in its entirety:

Those of you who are regulars here know them well, but I want to make sure those of you are new know about Science Mom and Catherina.

Although it would seem that with the frequency with which their names appear on these posts that they work for this site, they actually have no official affiliation with myself or this site. Although much of their scientific information seems to be accurate, I do not trust their opinions, their conclusions, or their advice. So, follow their advice are you own, and your children's, risk.

Many of us don't appreciate the way they redicule and demean anyone who is anti-vaccine. Most of us who are pro-vaccine, such as myself, are happy to offer advice or opinions to those who are not pro-vaccine, but we manage to do so in a respectful way. Because SM and Catherina don't seem able to do this, I suggest you simply ignore their posts and pretend they aren't there.

If you don't agree with them, don't bother trying to tell them so, no matter how solid you think your science is. Their science is better, or so they would think. I wouldn't waste your time arguing with them anymore, unless you enjoy that sort of thing - then, by all means, go for it.

There are rumors that SM and Cath are "secret agents" for vaccine manufacturers, planted here to combat my "anti-vaccine" advice. Although I wouldn't put it past any company to do just that (makes perfect sense - have a couple of "scientific" parents work the blogs and posts instead of doctors or professionals - some parents would listen more to another parent), I have no evidence that such is the case. SM and Catherina claim they spend hours on this site each week for almost two years now out of the goodness of their hearts. I would love to believe that, but I would also expect such good-hearted people to come across good-heartedly in their posts toward people who question vaccines. That clearly is NOT the case, so that makes me question what type of people they really are.

Anyway, just wanted to post this warning to any newcomers. I'm just going to pretend they aren't there and answer everyone's questions as usual. I'm sure ignoring them isn't going to make them go away, but they are SO NOT WORTH MY TIME anymore.

Where to begin? This infantile screed put forth by Dr. Bob smacks of anti-vax rhetoric, replete with accusations of "secret agents for vaccine manufacturers". How does one recognise that our scientific information is accurate but doesn't agree with it? What does that say of his 'scientific information'? Right, it's sorely lacking in every facet of his information and vaccine recommendations. A comprehensive review of this in his Vaccine Book: Making the Right Decision for Your Child a can be found on Science-Based Medicine.

While we are certainly thankful that he made it perfectly clear that we are not affiliated with him or his site, we can't help but laugh at the ad hominem attacks and his call for ignoring us, particularly with the caveat that our science is better. There aren't numerous branches of science; there are numerous disciplines of course, but all reside under the rubric of science and follow the scientific method. There aren't equally valid opinions or points of view; the whole point of science is to test hypotheses in an objective and repeatable manner, to minimise bias and allow us to determine if what we observe is real or not. This really shouldn't be difficult to understand, yet self-proclaimed experts like Dr. Bob continue to insist that there is somehow 'other science'. Yes there is, it's called pseudo-science and is not accepted by the scientific and medical communities for a very good reason. This does not make him or others like him Brave Maverick Doctors or open-minded; quite the contrary in fact given the very limited scope of what their pseudo-science parameters are.

We have nothing personal against Dr. Bob; we don't know him personally and given his chosen profession, we would certainly think that he is probably a nice man. But that is irrelevant really, for we are more interested in the bad science he and others like him espouse and the blatant misinformation they disseminate that put children in danger.

Seroconversion after measles or MMR vaccine

or: Dr. Bob strikes again

Dr. Bob Sears has a great sense of humour. He likes to drop a completely batty or offensive post, only to backpedal with a “just kidding” in response to expert critiques of his book. A recent gem on his blog on the upcoming H1N1 vaccines (which is astonishingly content free):

Just how bad is the H1N1 flu? Our experience so far indicates that it is a little worse than the regular flu, but it is not the rampaging epidemic that will sweep through the country and kill everybody. So why is the government so worried? It’s because the evil drug companies are paying them to act worried and create hype over the H1N1 flu so that the drug companies can make billions of dollars selling a vaccine that everyone will be scrambling for. The companies can then hand some of that money back to the government officials who helped them out.

Followed by an immediate

I jest.

In my opinion, he is not jesting, but rather “probing” his audience to see just how far out towards the fringe he will find most customers for his “alternative” schedule and books. This is all reasonably subtle, although Dr. Bob probably underestimates (or does he) how thoroughly his posts are read.

A couple of days ago, Dr. Bob struck again, although I am afraid, this one might turn into an explicit “recommendation” in the revision of “The Vaccine Book”:

Dr. Bob Answers by Dr. Bob - posted on 8/4/2009

I just found out some interesting info. I'd known this already, but hadn't realized it's [sic] implications.
ONE dose of the MMR vaccine creates immunity in 97% of kids. I had thought that the reason for the booser [sic] was that because this wears off, so another dose is needed. At an AAP lecture last month, this topic came up.
It turns out the second dose isn't a booster at all. A booster means that immunity wears off and needs to be re-boosted. The second MMR isn't given because imunity [sic] wears off (although eventually it does in adulthood). It's given to try to induce immunity in the 3% of children who don't respond to the first MMR shot. Doctors were also suggesting that it would make more sense to give two MMR doses during toddlerhood, so these 3% don't go through young childhood without protection.

So, this means that technically 97% of kids don't need that second MMR. It would make more sense to check titers on all kids, then only give the second dose to those who need it. some of the peds in my area actually do just that (they aren't anti-vaccine at all).

So, I'm thinking that this might be a good general policy for everybody. So, I'm considering not recommending a second dose, unless titers show it is needed. I will likely make this an official change in my alternative schedule. I just have to put a little more thought into this before I make this official.

However, the government doesn't recommend this because the healthcare costs of coordinating this type of thing for everybody would be very high - it's much cheaper just to give everyone a second dose, since the vaccine is harmless (?)

I (or YOU) may have just opened a can of worms.

(from this post - typos are his)

This is Dr Bob at his best, which unfortunately is not very good. Since his measles/MMR vaccine recommendations have major public health implications, let me summarize what we know (from the biomedical literature).

A good place to start are the vaccine package inserts. Here is the one for Attenuvax, the monovalent measles vaccine, usually produced by Merck, but on backorder at the moment (presumably until 2011) and the only monovalent measles vaccine licensed in the US. I am assuming this is where the “97%” that Bob quotes comes from. The package insert states that “97% or more” seroconvert, but “1 to 5% remain unprotected”. Seroconversion means that vaccinees who had no antibodies to the specific vaccine/disease show specific antibodies after disease or vaccination (the blood serum "converts" from negative to positive).

There is some (not much under that brand name) literature:

A small study looked at seroconversion depending on age. They vaccinated 15 15-months olds with Attenuvax, all 15 seroconverted (i.e. 100%). Then they vaccinated 6-months olds, 74% of 19 6-months olds vaccinated seroconverted, but had a lower titer than the older children. Significantly, upon boosting, all infants seroconverted and developed a higher titer. This is further confirmed by Erdmann and colleagues who find that titers can increase after revaccination or measles infection after one measles shot.
While these are small studies, they illustrate the principle that titers after one shot can be low and poor responders will be boosted by the second measles shot. This boosting effect of the second measles containing vaccine has also been observed in a very systematic MMR study from Sweden.

To dissect the 97%/100%-1 to 5% number in the package insert further, we can look at this larger study of over 600 children: Watson et al find that 5.4% of children at school entry who were initially vaccinated with monovalent measles vaccine at 15 to 17 months are non immune. This is the most realistic study I can find. The authors do not see an influence of age on seroconversion, so based on this available literature, we can assume that between 94 and 95% of children would seroconvert after vaccination with monovalent measles vaccine and remain immune until school entry.

The other possible vaccine, we can use to immunize against measles, is the MMR. The MMRii package insert states that seroconversion for measles is 95%. This is consistent with the majority of the available biomedical literature (see for example here and here). A huge number of studies using different measles containing vaccines consistently show a better immune response to the measles component in children older than a year (12, 15, or 18 months) vs infants (6 or 9 months). Dr. Bob consistently implies that the MMR vaccine given at age 4 would lead to sufficient seroconversion in most children (maybe extrapolating from the better responses in toddlers vs infants), however, the only paper systematically comparing the effect of age on seroconversion beyond the age of two finds that younger children respond better than the school age vaccinees.

Taken together, clinical data from Attenuvax and MMRii indicate a realistic rate of seroconversion of about 95% which would mean that up to 200’000 children per year/birth cohort in the US remain susceptible to measles after their first MMR/monovalent measles vaccine.

When devising a general vaccine recommendation, one cannot ignore the mumps and rubella components of the MMR. While the initial rubella seroconversion is consistently reported as excellent and near 100%, secondary vaccine failure occurs and leads to susceptibility during pregnancy. Currently, up to 9% of women in the US are found to be susceptible to rubella, having received a booster is highly predictable of protection at reproductive age. Even more dramatically, initial seroconversion to mumps can be variable (rates as low as 75% are reported in the literature, although values around 90% are more typical) and mumps immunity wanes with time, therefore putting a child who is not boosted at a significant risk (see for example here and here ).

So how practical is Dr Bob’s suggestion of one MMR at age 4 and a subsequent titer check and revaccination for the non immune as a “general recommendation”?

1. Children would go entirely unprotected for the first 4 years of their lives, leaving them vulnerable at an age when measles have a particularly high risk of complications, including SSPE.
2. After MMR vaccination at age 4, ALL children would need to have their titers tested. This involves a (sometimes very painful and traumatic) blood draw and titer tests for measles, mumps and rubella. Presumably, insurances will not pay for this (which doesn’t bother a doctor in private practise, like Dr Bob, but may lead to reduced compliance in the general public).
3. 5% of all children tested will not be immune against measles – more will have a low titer, up to 20% will not be immune against mumps, 1% or so will not be immune against rubella. Therefore, up to 20% of all children (or more, if you include the ones with low titer) would benefit from the second MMR.
4. All women would have to be re-screened before trying to conceive to see whether they are still immune to rubella.

I cannot give out medical advice, I am not an MD. However, given all available data, the strategy suggested by Dr Bob Sears seems to present a significant threat to public (and individual) health due to the long period he intends to leave children unprotected. His strategy is unnecessarily costly and complicated which may lead to a decrease in compliance and further increase in the number of susceptible children, then in a school setting where measles and mumps spread particularly well. In the long run, children who tested “immune” against measles, mumps and rubella and did not get the second MMR might lose measles, mumps and rubella immunity, contributing to outbreaks in high schools and colleges/universities. Women may lose rubella immunity, leading to a re-emergence of congenital rubella syndrome.

A general vaccination schedule comprising 2x MMR, the first one at age 1 (12 to 15 months) and the second one between 4 and school entry is safer (immunity earlier, better long term immunity for every child), cheaper (no titer tests) and easier to follow (fewer doctors’ visits). Unless, of course, one considers the second MMR as some unmeasurable danger that is best avoided, which brings us back to Dr. Bob’s MMR recommendations and his true beliefs. Does he really believe the second MMR would be so traumatic that it is worth avoiding it at the above mentioned expenses (both medical and financial), or is this “new” recommendation a plot to keep the “brave Maverick doctor" label when all science points to no connection between MMR and neurodevelopmental disorders? Certainly, Dr. Bob is more brazen about his choice of professional alliances of late, moving further and further away from a position that would be acceptable for any "majority".

edited within first hour of posting to fix links and typo

The MMR-Autism Claim and Bad Science: Part II

Our previous post discussed the first 3 of 7 studies that appear in The Vaccine Book by Dr. Bob Sears that he claims supports Wakefield et al. (1998). We will now discuss the last 4 as they appear in the book on pages 258-259. The fourth is by Goldman and Yazbak (2004) and this is Dr. Sears' summary:

This group studied the incidence of autism in Denmark before the MMR vaccine was introduced compared to its incidence in the years thereafter. They found about a 400 percent increase in autism over those years. This group used the same data as the two Denmark studies listed on page 259, which concluded that there is not enough evidence to link mercury in vaccines to autism. In this study, however, Goldman's group concluded that there may be a link between the MMR vaccine and autism in Denmark.

It is important to mention that the Goldman and Yazbak study was published in a journal called the Journal of American Physicians and Surgeons is neither peer-reviewed nor indexed and is essentially an online magazine for those that fancy themselves scientists. Before we review the Goldman and Yazbak study, we have to discuss the study by Madsen et al. (2002) which the aforementioned study is predicated upon. Briefly, Madsen et al. examined records from entire birth cohorts born between January 1. 1991 to December 31. 1998 to look at autism diagnoses between those vaccinated with MMR and those unvaccinated with MMR. They found that there was the same risk of developing autism or an autism spectrum disorder (ASD) in both vaccinated and unvaccinated children. The adjusted relative risk of autistic disorder was 0.92; 95% confidence interval (0.68-1.24) and the adjusted relative risk of other ASDs was 0.83; 95% confidence interval (0.65-1.07) (these confidence intervals will become more relevant later). There was no association between autism diagnosis and age of vaccination or the interval since vaccination. There was also no clustering of autism or ASD diagnoses around the time of vaccination.

Goldman and Yazbak (2004) attempt to critique the Madsen et al. paper and conduct their own statistical analyses. They start by stating:

Because autism is usually diagnosed at age 5 or older in Denmark, many children born in 1994 and thereafter would not have been diagnosed by the end of the study period. The systematic error of missing a large number of autism diagnoses in the later years was a major shortcoming. Children with Asperger's Syndrome and high-functioning autism, who have minimal speech impairments and are thus not diagnosed as early as more profoundly affected children, are especially likely to be undercounted in this study.

The Madsen et al. group reported a mean age of autism diagnosis at 4 years, 3 months and the mean age of other autism spectrum diagnoses was 5 years, 3 months. They also cut-off study observations on December 31. 1999 allowing for an additional year of observation which Goldman and Yazbak fail to mention, so some children born after 1995 may have received an ASD diagnosis after the cut-off date. To be fair, however, the Cochrane Database Systematic Review criticized the unequal length of follow-up and the use of the date of diagnosis rather than symptom onset. However, they still used it in their review and concluded:

No credible evidence of an involvement of MMR with either autism or Crohn’s disease was found.

The Madsen et al. (2002) study had a total population of 537,303 (2,129,864 person-years), 440,655 (1,647,504 person-years) in their MMR-vaccinated group and 96,648 (482,360 person-years) in their unvaccinated group. They identified 738 cases of ASDs, which provides ample statistical power to their study to detect an association between MMR and ASDs, if there was one. They also relied upon autism diagnoses that are made by specialists in child psychiatry, rather than onset of symptoms which would have introduced reporting bias. Reporting bias can occur if the investigators relied upon parental reporting of symptom onset as many behaviours of ASDs could have existed prior to vaccination and missed. Whereas administration of a vaccine is a profound event and has confounded the actual onset of an ASD . If MMR causes regressive autism within days of vaccination, then a diagnosis would follow shortly thereafter and not deferred for years as Goldman and Yazbak imply. Additionally, Madsen et al. (2002) adjusted for age and time of follow-up. Goldman and Yazbak also state:

Additional flaws in the Madsen study included the unusual distribution of ages in the cohorts, censoring rules applied to cases, and failure to separate autism into regressive and classical cohorts. These and other cited methodological and statistical problems tended to mask the association with MMR vaccine, as unimmunized children were clustered in the earlier years of the study so that ascertainment was more complete in this cohort than in those immunized a few years prior to the end of the study period, when many cases of autism were missed owing to insufficient follow-up time to make the diagnosis.

yet didn't state exactly why these were a problem. There was not an unusual distribution of ages in the cohorts because Madsen et al. (2002) used population data so this ridiculous criticism can best be summed up by a quote from Adam Jacobs in his critique of the Goldman and Yazbak study, who said, “In any case, it seems a little harsh to blame the Danes for the rate at which they breed.” They also mention censoring rules but fail to explain how they were a problem. Not only were the censoring rules in the Madsen et al. (2002) study very rational, but amounted to less than 1% of their entire study cohort.

Follow-up of 5811 children was stopped before December 31, 1999, because of a diagnosis of autistic disorder (in 316 children), other autistic-spectrum disorders (in 422), tuberous sclerosis (in 35), congenital rubella (in 2), or the fragile X or Angelman’s syndrome (in 8), and because of death or emigration in the cases of 5028 children, whose data were censored.

So what this means is that the 738 children that received ASD diagnoses were not followed up after that; there was no point as they were diagnosed and included in the final analyses. Forty-five children received an autism diagnosis disorder due to genetic disorders so weren't relevant to examining an MMR-autism causation. Madsen et al. (2002) did include these 45 children in an analysis and it didn't change the results. The rest, 5028 children either died or emigrated thus isn't possible to include them in the final analyses so this amounts to a loss of 0.94%; quite a negligible percent. Again Goldman and Yazbak's assertion that only older children were likely to be diagnosed with an ASD is completely contrary to their argument that MMR causes regression within days and not years.

Then what Goldman and Yazbak do defies logic; they don't do any statistical analyses that even remotely resembles what Madsen et al. did. In fact, they perform a statistical smoke and mirrors show that Penn and Teller would have a field day with (if that was their shtick). The MMR was introduced in Denmark in 1987 and a change in diagnostic criteria for ASD diagnoses changed in 1993. Goldman and Yazbak took the 3 years preceding the diagnostic change, 1990-1992, tortured the data, then extrapolated the rate of diagnoses out to 2000, then claim a 370% increase in ASDs after the introduction of the MMR vaccine. If you look at their Figure 1, there isn't any increase in ASDs following MMR introduction and even prior to the classification change, there would be if MMR vaccination was responsible for regressive autism according to their own claim. They say:

The true confidence intervals are wider than indicated because of error associated with linear regression of the trends both before and after 1994.

No, you don't do this, confidence intervals must always be reported; they tell you the reliability of an estimate and the higher the confidence level, the wider the interval will be, depending upon the reliability. That width indicates the true range of an estimate so if they are narrow, i.e. the confidence intervals reported by Madsen et al. and thus their relative risk is highly accurate. Compare this to the confidence intervals that Goldman and Yazbak failed to report; Grove and Jacobs were kind enough to calculate Goldman and Yazbak's 95% confidence interval, which was -3.57-82.6. This is absurd and most likely why they didn't report it; in other words, their 'predicted' autism prevalence based on their 1990-1992 data spanned negative numbers. This isn't even the best part; a crucial factor is missing from their analyses, intentionally:

Because we did not request population data stratified by vaccination status, we were unable to compare vaccinated and unvaccinated cohorts as had been done in historical studies. Instead, since the vast majority of children aged 5 to 9 years received MMR vaccine, we compared autism principally in this age group in periods before and after introduction of the vaccination program.

Hey, why let some trivial detail like whether a child received the MMR vaccine get in the way of statistical analyses to determine if MMR vaccination is causing an increase in ASD prevalence. They did not use the same data as Madsen et al. (2002) did nor did their data manipulation support an MMR-autism association as Dr. Sears claims. There is simply no defense for such abuse of statistics to intentionally deceive readers.

The fifth study is by Bradstreet et al. (2004) and is not only a little gem that appears in Journal of American Physicians and Surgeons but features Wakefield as a co-author. This is Dr. Sears' summary:

This group found measles virus RNA in the CSF and intestinal biopsies of three children who had gastrointestinal inflammatory disease and autism. The only known exposure these kids ever had was from the MMR vaccine. Three control patients did not have measles detected in their samples.

They don't get off to a very good start by reporting:

All have received multiple interventions ranging from dietary modification to intravenous immunoglobulin, though the details of these interventions and the relevant outcomes are not reported here.

That's like conducting a study on tomato yield of different plants, but using various watering and fertilisation strategies and deeming these variables unimportant to control for and report. Since they are testing for anti-measles antibodies, it is kind of important to control for the fact that the children are receiving immunoglobulin, at the very least. And once again, they are relying upon parental reports of regression without validating with medical records.

Their methods for viral detection rival those of what you would expect from "Sid the Science Kid". But in actuality, are worse for they sent their samples to Unigentics and all of the same parameters as Uhlmann et al. (2002) which were de-constructed in our first post of this series. They also used Singh et al. (2003) poorly defined immunoblotting and anti-MBP assays; neither of which has been validated nor standardised for diagnostic value.

Results of CNS autoantibody and virus IgG profiling are shown in Table 3. MBP autoantibodies were present in the serum of all three children and CSF of children 1 and 2. NFAP antibody was present in the serum of child 2 only. MV IgG antibody titers were reported as high in the sera of children 1 and 2, and detectable at a low level in the CSF of these same children. MVIgG antibody titer was reported as being within the normal range in the serum of child 3 and undetectable in his CSF. Where samples were analyzed for the previously reported MMR-associated antibody, they were negative. Human Herpesvirus-6 serology was unremarkable, and specific IgG antibody was not detected in CSF of the two samples in which it was sought (children 2 and 3).

It is curious that they reported anti-measles IgG antibody as high in some of the autistic children yet didn't report the results from their “control” children. There is no “normal range” of these antibodies and a high titre is not indicative of anything. And given that some or all of these children were treated with “immunoglobulin therapy”, it's not surprising that their titres would be elevated.

Bradstreet et al. (2004) too, did not sequence their PCR amplicons, which is standard practise, that is if investigators are actually interested in the accuracy of their results. What they lack in proper methods, they try to compensate for with a bloviated discussion, that of course, is corroborated by all of the junk science that preceded. While they test for anti-MBP autoantibodies in the autistic children, they do not test the “control” children and they don't explain their results which are presented as a throw-away sentence and merely buried in a table. One wonders why they would even mention their significance in their background, not test their “controls” for them and then not explain their results nor their significance, not that they really have any. We hope you aren't getting bored but this is nothing more than yet another foray into the world of pseudo-science.

The sixth article Dr. Sears cites as “showing a link between MMR vaccine and autism” is by Kushak et al. (2005) and is actually not a published study at all but a poster presentation and what you see is the extent of it unless you attended the conference that it was presented in. This is Dr. Sears' summary:

This Harvard group essentially reproduced Dr. Andrew Wakefield's work by finding chronic inflammation, lymphoid hyperplasia, and digestive enzyme deficiency in the gastrointestinal tract of numerous autistic children. It didn't explore a possible link to measles infection from the MMR vaccine, however.

We don't see what their Harvard affiliation has to do with anything. This group did not 'reproduce' Wakefield et al.'s work; they merely examined gastrointestinal problems in autistic and non-autistic children and some enzyme values. They didn't find any significant differences in gastrointestinal problems between autistic and non-autistic children but did find some abnormal enzyme levels in the autistic children as compared to the non-autistic children that were statistically significant. Which could be easily explained by diet. We don't see how Dr. Sears came to the conclusion that the investigators found “chronic inflammation, and lymphoid hyperplasia” in any of the children when that wasn't even reported. Since this was a poster presentation in abstract form, and has absolutely nothing to do with Wakefield's findings, there is really nothing to evaluate here.

Onto the seventh and final study by Geier and Geier (2004) and this is Dr. Sears' summary:

This group studied the increase in autism over the past twenty years compared with the timing of increased thimerosal vaccines and the introduction of the MMR vaccine and found evidence that these may play a role in neurodevelopmental disorders. They recommended taking thimerosal out of vaccines and finding a safer MMR vaccine.

It is important to first point out the Geier's conflict of interest statement in this publication, which is:

Dr. Mark Geier has been an expert witness and a consultant in cases involving adverse reactions to vaccines before the U.S. Vaccine Compensation Act and in civil litigation. David Geier has been a consultant in cases involving adverse reactions to vaccines before the U.S. Vaccine Compensation Act and in civil litigation.

Also of interest is that they were developing a patent application for their Lupron Protocol which was submitted later that year. For more about the Geier's situational ethics and conflicts of interest, you can read Kathleen Seidel and Respectful Insolence. Onto the actual study.

The Geiers used U.S. Department of Education (DOE) datasets to determine autism prevalences. These data are going to show children receiving services for autism as it was diagnosed at that time. They also used CDC birth surveillance data for the estimations performed on birth cohorts from 1981-1985 and 1990-1996, leaving out 4 years, 1986-1989. There was no explanation as to why. In order to 'determine' thimerosal exposure they used the Biologic Surveillance Summaries of the CDC, of course not knowing actual vaccines received by the infants. These methods alone render this 'study' completely useless but being the brave souls we are, will forge ahead anyhow.

They essentially did the same thing as above for the estimation of MMR vaccine and autism prevalence but had even larger gaps in their data. They only used the years 1982, 1985 and 1991-1996, with again, no explanation but their exclusion becomes obvious later with our discussion of Figure 3. Stay with us here because this makes little sense; they took their selected birth cohort years, pulled out the DOE autism prevalences corresponding to those years, estimated the autism prevalence for the birth cohort and banged them together for their MMR-autism prevalence estimate. The children receiving MMR would have been too young for an actual autism diagnosis. And why bother with pesky details about when and which children were actually vaccinated when the desired results have been pre-determined? For instance, they decided to use the 1984 birth cohort as a 'baseline' but their explanation as to why is nonsensical because they haphazardly used several birth cohorts instead of tracking one which seriously confounds results due to changes in diagnostic criteria, special education expenditures, birth cohort size and ages of diagnoses. None of which they controlled for.

What they also fail to account for, particularly in the earlier cohorts for their thimerosal exposure table (Table 1) is the 1982 recommendation for Hepatitis B vaccine for infants and contained thimerosal. In other words, their Table 1 is even more wrong and skews the mercury exposure higher for later birth cohorts. So on to their other results:

In Figure 2 we plotted the average mercury dose per child in comparison to the prevalence of autism per 100,000 children for successive birth cohorts (birth cohorts: 1981 through 1985 and 1990 through 1996). Figure 2 shows that as the prevalence of autism increased from the birth cohorts from the late 1980s through the early 1990s a corresponding increase in the average mercury dose per child occurred. A maximum occurred in the birth cohort of 1993 in both the average mercury dose per child and the prevalence of autism. A decrease in both the prevalence of autism and the average mercury dose per child occurred from 1993 through 1996.

This is best described by showing you Figure 2:

If their data crunching wasn't bad enough, they seem to happily torture them graphically. As you can see, they omitted the years 1986-1989 (with no reasoning) but still presented the gap as continuous data. You just don't do that, plain and simple so at best, they are buffoons and at worst, liars. They also claim that the prevalence of autism concomitantly decreased with thimerosal exposure. No, no and no; autism prevalence did not decrease, anyone reading this knows that and their thimerosal exposure estimates are rubbish to begin with. As for Figure 3:

Figure 3 shows the number of doses of primary pediatric measles-containing vaccine in comparison to the prevalence of autism for each birth cohort examined (birth cohorts: 1982, 1985, and 1991 through 1996). This figure shows that there was a potential correlation between increasing doses of primary pediatric measles-containing vaccine and an increasing prevalence of autism during the 1980s. We determined that the slope of the line was 4831, and the linear regression coefficient for the line was 0.91.

These are the estimates for which they omitted even more years and they came up with a correlation. They could have plotted the number of artificial satellites we have in orbit or the use of smilies in internet communication and come up with a correlation. As a rule of thumb, when you want to just 'eyeball' such a graph for potential problems, remove any 2 data points and if the trend line disappears, there could be a problem. Let's take off their 1982 and 1985 data points; the trend line completely disappears. We consider the imminent possibility that the other years were intentionally omitted because they didn't plot to their liking.

Figures 1 and 4 and their corresponding results are really nothing; garbage in, garbage out. They again, cherry-picked certain years to report for Figure 4 that had no statistical significance, in spite of what they report (overlapping confidence intervals bugger up significance like that). It is also curious that this 'study' was written in 2003 but the Geier's didn't bother to use data after1996 nor acknowledge that thimerosal has not been in vaccines, or in trace amounts since 2001 and yet autism prevalence has continued to rise. The Institute of Medicine's 2004 Immunization Safety Review: Vaccines and Autism said of this study and others by the Geiers:

Other studies reported findings of an association. These include two ecological studies⁴ (Geier and Geier, 2003a, 2004a), three studies using passive reporting data (Geier and Geier, 2003a,b,d) one unpublished study using Vaccine Safety Datalink (VSD) data (Geier and Geier, 2004b,c), and one unpublished uncontrolled study (Blaxill, 2001). However, the studies by Geier and Geier cited above have serious methodological flaws and their analytic methods were nontransparent, making their results uninterpretable, and therefore noncontributory with respect to causality (see text for full discussion).

Dr. Sears over-inflates the results and importance of this heavily-biased study. They did not examine 20 years worth of data, at best it was 12 years and a poor job at that and didn't find any evidence that MMR, or thimerosal played any role in neurodevelopmental disorders. They are a little late to the game too if they are recommending that thimerosal be removed from paediatric vaccines when that was done 2 years prior to their 'study'. What would a safer MMR look like anyhow?

This concludes our series critiquing the studies Dr. Sears uses to support Wakefield's findings. So are you sensing a theme here? That is, bad science manages to find an MMR-autism connection, whereas good science cannot. As parents that are concerned with these issues, you should be angry, very angry. You are being bamboozled, hoodwinked, taken for a ride by these charlatans that rely upon the scientifically unsophisticated to just read introductions and discussions but gloss over the methods and results. This is the way these 'scientists' can be broken down:

A.) They are too inept to perform sound, methodological science.

B.) They aren't too inept but believe these claims and don't mind cutting corners, being the mavericks they are.

C.) They have an agenda, financial or otherwise and laugh at the ease by which they can take advantage of the naive and desperate.

If anyone can come up with a valid, alternate explanation that doesn't involve Galileo or Copernicus, we're listening. Maybe we are preaching to the choir and if so, you can feel assured about your own conclusions, but if we are not, we hope that you can at least, begin to break free of the grip of pseudo-science that makes you feel overwhelmed by the glut of information. That there really isn't two sides of this issue that are equally valid and perhaps you are better equipped to spot junk science.

The MMR-Autism Claim and Bad Science: Part I

Recently, some participants on Dr. Bob Sears The Vaccine Book Discussion Forum asked about the validity of his references that show a possible link between the MMR vaccine and autism. The list appears in The Vaccine Book: Resources pp. 257-259 (2007). So why would Dr. Bob believe that these studies support Wakefield's findings? Well, if you just read abstracts and conclusions, then you could easily make that mistake. But the devil's in the details and in this case, the details are extremely shoddy methods and scientific dishonesty. There are 7 'studies' and we will discuss these in a 2-part series, as they appear in the book and closely examine the methods.

The first is the original article by Wakefield et al. (1998) and this is Dr. Sears' summary:

This is the landmark study that began the whole debate. Wakefield found twelve children who developed regressive autism during the second year of life (after the MMR vaccine was given) who also had intestinal inflammatory disease consistent with a viral infection, probably measles related. See page 94 for further discussion.

The information on this paper is exhaustive and you can start by reading the numerous comments from the original Wakefield paper. Ten of the original 13 authors listed a Retraction of the Wakefield et al. paper and this is an excerpt:

We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient. However, the possibility of such a link was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper, according to precedent (Zhang et al.).

So several things happened prior to and after that retraction and the most comprehensive explanation can be found on the website of journalist Brian Deer. While he is a journalist, his reports have held up to scrutiny and are, in part, the foundation for the General Medical Council's (GMC) disciplinary proceedings against Dr. Andrew Wakefield and Professors Simon Murch and John Walker-Smith. It is also a plain-English summary. Additionally, compelling evidence of both scientific fraud and abysmal methodologies came to light during the Omnibus Autism Proceedings (OAP), specifically by the testimonies of Dr. Nicholas Chadwick and Dr. Stephen Bustin. Dr. Chadwick was Andrew Wakefield's graduate student at the time of the now infamous MMR-autism study and could not find measles virus in some samples from work prior to the MMR-autism study. He notified Dr. Wakefield of this, who proceeded to report them as positive anyhow via a paper co-authored with Kawashima et al.; Dr. Chadwick asked that his name be removed from any publication that included these results. Incidentally, Dr. Wakefield was not asked to testify at the OAP.

An explanation of Dr. Bustin's testimony can be found here which also discusses the difficulties with the results found in the next paper to be discussed. In short, Wakefield et al. and subsequent studies seemingly supporting Dr. Wakefield's findings did not find what they claim they found. The researchers didn't take any of the simple measures to ensure the quality of their work and verify their findings. This was a scientific fraud shot-heard-around-the-world.

The next paper is by Uhlmann et al. (2002), which includes Wakefield as a co-author and this is Dr. Sears' summary:

This eleven-doctor group in Ireland did intestinal biopsies on a large group of children with autism and found that of the ninety-one who showed ileal lymphonodular hyperplasia and enterocolitis, seventy-five had confirmed measles virus infecting their intestinal linings. Only five of the seventy healthy control patients tested showed the measles virus. This study offers more support for Dr. Wakefield's claim of a link between measles virus, inflammatory bowel disease and autism.

Before we get to the methods, let's briefly jump to the conclusions. O'Leary's lab found that 82.4% of the children with developmental disorders had measles vaccine virus in their guts. This, by itself is astonishing and should be questioned. By these reported numbers, an investigator that wishes to verify these study results would only have to have a sample size of 6 autistic children (95% confidence interval) to detect a significant number of children with measles vaccine virus as compared to controls; this will become more relevant later.

Now for the methods; there was a control group and a developmentally delayed group but no effort was made to actually match the groups or describe their differences other than developmental status. But one of the most important and fatal flaws with the study, was the molecular tests that they carried out. Again, the full testimony of Dr. Stephen Bustin is available. The Uhlmann group, working in Dr. John O'Leary's now-defunct Unigenetics laboratory in Ireland did not describe their controls in a manner that could control for contamination or other investigators could parse. They also used source material that would have been degraded, and thus rendered useless by the methods they were using to detect measles vaccine virus sequences. The primers that are used to detect a particular sequence of interest, in this case, measles vaccine virus, were mismatched which increases the likelihood that a non-target sequence could be detected. But the most crucial flaw in this methodology is that the investigators never sequenced their results. Sequencing maps out the nucleotide arrangement for the target that was amplified; you then compare that to a DNA library such as GenBank which is a repository for millions of sequences. This would have told them (as it did Dr. Chadwick) that what they were getting was not measles vaccine virus but something else.

It was also noted in Dr. Bustin's audit of Unigenetics operating procedure for the Uhlmann et al. paper, that measles is an RNA virus and there was no RNA in many of their samples yet they used them and counted them as positives. Also, in some cases, they skipped the reverse-transcription (RT) step which converts the RNA to DNA and miraculously still found positives, which would be impossible and is therefore yet another crucial flaw in this experiment. The laboratory was located adjacent to a plasmid room. Since PCR is prone to contamination, all measures must be taken to ensure clean runs and control for contaminants. Plasmids are a source of this and since many people were walking in and out of the rooms, plasmids could easily make their way into reaction vessels. Again, sequencing would have shown them that, yet they refused to utilise this very basic (and inexpensive) technique. Unigenetics gave their samples to another investigator to replicate (as part of an investigation that was going on in the U.K.) and he could not get the same results with the proper extraction and PCR methods. Now Dr. Bustin was under oath to provide his professional observations of his audit of Unigenetics and accordingly, did not speculate about the Uhlmann et al. study. We are not under those constraints and will daresay the extraordinary lopsidedness of their results, does point to scientific fraud.

Two groups of investigators attempted to replicate Uhlmann et al.'s study and could not get the same results. The first study is by Afzal et al. (2006) who replicated the parameters of Uhlmann et al. BUT with more sensitive molecular methods, proper controls and quantification of starting RNA. They took blood samples from 15 children with autistic disorders that had the MMR jab, 10 of them reportedly regressed in the second year of life and after the MMR jab. They specifically examined leukocytes (white blood cells) because if there is measles virus replicating in their guts as Wakefield et al. contends, then evidence of the virus is going to be found elsewhere. Incidentally, Dr. Afzal asked Wakefield/Uhlmann/O'Leary for their samples to be tested but were refused, which in itself is highly unusual in the scientific community. Afzal et al. did not detect any measles virus, vaccine or wild-type in the children. Although their sample size was small (n=15), given the 82.4% of children with measles vaccine virus present that Uhlmann et al. claimed to have found, they should have detected 6 positives.

A relatively small number of patients was examined in this study. However the reported frequency of positive samples in the largest positive study is about 82% (Uhlmann et al., 2002). While it is impossible to prove a negative, it is clear that this figure is not consistent with zero positive from 15 as here. In fact if the null hypothesis is that 82% of patients have measles sequences, it would be inconsistent with fewer than 6 positives from 15 samples at the 95% confidence level. The failure to find any positives means that the incidence is far lower than this, and possibly zero.

The second study is by D'Souza et al. 2006 and followed the Uhlmann et al. and Kawashima et al. protocols even more closely but with, again, better precision and optimisation of their methods. They used peripheral blood mononuclear cells (PBMCs) which are a perfectly acceptable surrogate for gut biopsies or cerebral spinal fluid. They also had a larger study group with controls and their characteristics included gastrointestinal complaints and the majority receiving 2 doses of MMR:

Fifty-one of 54 children from the ASD group and 31 of 34 from the control group had received MMR vaccine. From the ASD group, 2 children had not been vaccinated, and 1 child’s status was unknown. From the control group, vaccination status was unknown for 3 children. The majority of children with ASD (n = 43; 84%) and the developmentally normal children (n = 28; 90%) had received 2 doses. The Quebec immunization schedule recommends a 2-dose MMR schedule at ages 12 and 18 months.¹⁴ Only 1 (control) child had received 3 doses. Gastrointestinal symptoms, including constipation, cramping, diarrhea, and abnormal stools, were reported in 43 (79.6%) of 54 children from the ASD group and 11 (32.3%) of 34 children from the control group. Regression was reported in 20 (37%) of 54 subjects in the ASD group. The time between vaccination and blood analysis was similar between the 2 groups. The mean time (±SD) between vaccination and blood sampling for the ASD group was 30.4 (±15.9) months and 26.6 (±15.3) months for the control group (2-tailed t test, p = 1.056, not significant).

And their results:

The majority of samples generated positive results in the Uhlmann assays. However, melting curve analyses revealed that only a proportion of these PCR products had the correct melting temperature (ie, identical to the positive MV control). Furthermore, only 2 products generated by the Uhlmann nucleoprotein assay, 3 by the Uhlmann fusion assay, and 4 by the Uhlmann hemagglutinin assay had the correct amplicon size when separated by gel electrophoresis. We successfully obtained sequences for 7 of these 9 products, but none were MV RNA. No specimen was positive using the Kawashima primer-based assays or our own probe-based fusion gene assay.

This is in line with Afzal et al.'s results and again, since almost 80% of the children had gastrointestinal complaints, a minimum of 6 positives should have been detectable if present.

The third paper in the first part of this series is by Thompson et al. (1995) also includes Wakefield as a co-author and this is Dr. Sears' summary:

This group of doctors studied thirty-five hundred adult patients with inflammatory bowel disease and other chronic intestinal conditions who had received the single measles vaccine in 1964 as part of the vaccine safety trials. When compared to a control group of eleven thousand adults who didn't get the measles vaccine, the vaccinated people were three times more likely to develop inflammatory bowel disease. This study predates Dr. Wakefield's work and is consistent with his concern about a link between the measles vaccine and inflammatory bowel disease.

No, it isn't Dr. Sears and this is why. This paper is merely an attempt to validate results from a previous paper by Lewin et al. (1995) of which (surprise surprise) Wakefield is a co-author of.

Groups were recruited from different study populations with no attempt to match or control for differences that would also contribute to or explain prevalence of intestinal bowel disorders (IBD). Information obtained, such as measles vaccine history and IBD history from the control group (not supposedly vaccinated for measles) was sloppy and relied heavily upon self-reporting. Essentially comparing apples to oranges. This introduces considerable bias potential because there is no standardisation of data collection regarding exposures and disease outcomes so the investigators didn't have all of the information that could be potential confounders for the measles jab. And this is the case as you will see.

Their methods for measles detection (as explained in the Lewin et al. paper) were prone to cross-reactivity with other antigens so they couldn't actually claim that they found measles without other molecular detection methods for viral presence. Other investigators had failed to find evidence of measles virus in gut biopsy samples of IBD patients using much better detection methods, if one could be bothered to read the comments published in the Lancet about this paper. They are really quite helpful, particularly if one is unsure of how to read and understand the methods of a controversial study. We highly recommend doing this.

Another problem with this study is that the authors postulated that measles infection, therefore attenuated, live, measles vaccine is a risk factor for IBD (which includes Crohn's disease and ulcerative colitis). Thompson et al. found a significantly lower risk of IBD in the unvaccinated control group as compared to the vaccinated group. This is incongruous with their hypothesis because 85% of the unvaccinated control group reportedly had natural measles infections versus no natural measles infections in the vaccinated group. If measles infection is associated with a higher risk of IBD you would expect to see higher numbers in the control group. This just further demonstrates the selection bias and slipshod methodology used to ascertain this association. A criticism of this study (published in the comments) deigned to point out that:

The relative risk of measles vaccinees developing inflammatory bowel disease compared with unvaccinated individuals (relative risk 2.5-3.0) should be in perspective: Crohn’s disease is more common in subjects whose first house had a hot water tap (odds ratio 5.0).

In other words, there is a stronger association between those that had hot water in their house as children and IBD, than those that received the single measles jab. It is interesting to note that even Wakefield himself has backed away from this work (Chadwick et al. 1998).

These papers are not independent replications of Wakefield's 1998 Lancet paper other than all being slapdash works that range from appalling incompetence to seemingly outright fraud. They and their supporting works all have Wakefield as a co-author on them. We will review the next 4 studies Dr. Sears claims 'support' Wakefield's work listed in The Vaccine Book in the next coming weeks.

ETA 07.19.09 for accuracy.

Measles in Brooklyn

I don't know why they waited so long with the health alert, but here it is:

http://tinyurl.com/nnel9k

A measles alert was issued yesterday by the city's Health Department after an outbreak of 11 confirmed cases and one suspected case, all in the Williamsburg and Borough Park sections of Brooklyn.

The 12 cases identified over the past two months involve 10 children, between the ages of 8 months and 4 years, and two adults, according to the Health Department.

The alert sent to physicians and other health-care providers states that "most of the cases have had a close contact with each other" and that "in one instance, transmission may have occurred in a physician's waiting room." None of the 12 had been vaccinated.

The cases are still under investigation and officials were sketchy on details.

/...snip.../

Dr. Jane Zucker, an assistant health commissioner with the bureau of immunization, acknowledged that some parents have expressed concern about the measles vaccine and want to wait until their children are 3 or 4 years old. But she cautioned against such delays.

The advisory urges doctors to be alert for measles symptoms and immediately report clinically suspect cases to the department.

My bold: this is why I think that delaying MMR until the age of 3 or 4 is dangerous.

Note that once again measles appear to have spread in a doctor's waiting room - if I was a pediatrician, unvaccinated patients would make me nervous, too (see my earlier blog on SSPE in children who caught measles as babies in their pediatrician's waiting room - that fate is still looming over the children in Brooklyn).

The Toxin Gambit Part 1: Formaldehyde

We will be conducting a multiple-part series describing some of the vaccine constituents that many consider 'toxins' or just have what the actual chemical is, just plain wrong. The first part of our series will be dedicated to information regarding formaldehyde, what it is, why it is in vaccines and any health implications. So thank you to Valo for your suggestion.

For the purpose of this series, it is important to understand the metric scale, not so much the actual measurements but their relationship to one another. For example, if a microgram (mcg) is a grain of sand, then a milligram (mg) is a slice of American cheese, so a gram (g) is an average 5.5 year-old boy and a kilogram (kg) would be 7 H2 Hummers. Again, these aren't actual weights, volumes or measurements, but rather, their differences on a visual scale.

Formaldehyde is a naturally-occurring chemical that can also be synthesised. The chemical formula is CH2O and is also known as methanal (not to be confused with methanol), formal and methyl aldehyde. It is also not to be confused with formalin, which is an aqueous solution of formaldehyde. Numerous isomers of formaldehyde exist but they are not formaldehyde. It is used in the manufacture of resins that are then used for the production of pressed wood products, paper, textile fibres, adhesives and plastics (EPA 2009 and WHO 2006). Of course, those involved with the manufacturing of products with formaldehyde may sustain occupational exposure and subsequent pathologies (EPA, 2009 and WHO, 2006). Formaldehyde is also a by-product of tobacco smoke and combustion reactions from stoves, kerosene space heaters and automobiles (EPA 2009).

Naturally occurring sources of formaldehyde are found in plants, fruits, vegetables, animals (including humans) and seafood (Mason et al. 2004 and Inchem 1989). Table 14 of the Environmental Health Programme on Chemical Safety: Formaldehyde, and Table 95.2, Chapter 95: Formaldehyde, lists some commonly-consumed foods and their formaldehyde concentrations. (Clary and Sullivan 2001 and Inchem 1989). In a study of Shiitake mushrooms, investigators reported formaldehyde concentrations of 100-300 mg/kg; this wide variation is a result of a combination of analysis techniques, naturally-occurring formaldehyde and also possible contamination with exogenous formaldehyde (Mason et al. 2004).

Formaldehyde is a normal, essential human metabolite with a biological half-life of about 1.5 minutes (Clary and Sullivan 2001). It is endogenously produced and is involved with methylation reactions for and biosynthesis of some proteins and nucleic acids. It is also rapidly metabolised to formate and excreted in urine or to carbon dioxide and exhaled (WHO, 2006 and Clary and Sullivan 2001). Some common routes of exposure for exogenous formaldehyde include dermal, from occupational handling, inhalation, from occupational exposure and environment, oral via dietary intake and of course, intramuscularly or subcutaneously from vaccines. (Franks 2005, Clary and Sullivan 2001 and Inchem 1989).

Human normal blood concentrations of formaldehyde are 2.74 +/- 0.14 mg/L (Franks 2005). The average adult male (86 kg) in the U.S. has a blood volume of 5.8 litres; the average adult female (74 kg) has a blood volume of 5.0 litres and an average 2 month old infant (5 kg), 0.43 litres. So this translates to 15.1-16.7 mg of normal formaldehyde range in an adult male, 13.0-14.4 mg in an adult female and 1.1-1.2 mg in a 2 month-old infant which works out to be 0.22-0.24 mg/kg (CHOP 2008 and Franks 2005). Using the visual scale provided earlier for the infant, that would be a little more than 1 slice of American cheese/35 H2 Hummers.

Toxic levels of formaldehyde can induce a variety of illness from localised skin/respiratory tract irritation to cancer (Bosetti et al. 2008, Sundstrom et al. 2001 and Pandley et al. 2000). Inhalation of 1.0-2.0 parts per million or ppm (ppm=mg/kg) is considered mildly irritating, while 3.0 ppm causes moderate eye irritation although there is variation of sensitivity in individuals (Sundstrom et al. 2001 and Inchem 1989). Chronic inhalation studies on rats and mice have resulted in nasal cavity squamous cell carcinomas, when exposed to levels above 6-15 ppm (Bosetti et al. 2008 and Clary and Sullivan 2001). Formaldehyde toxicity resulting in death occurs in humans at a volume of about 60-90ml (Pandey 2000). The CDC conducted a survey of 'travel trailers' used for displaced people from hurricanes Katrina and Rita and found levels ranging from 0.003-0.59 ppm with an average of 0.077 ppm (CDC 2008). Thus far, only symptoms of local irritation have been reported (CDC 2008). A 2005 study of single-family homes in 3 cities detected an average of 0.17 ppm and 0.016-0.025 ppm in travel trailers (Weisel et al. 2005).

Formaldehyde in vaccines is left over from the production process, where it serves a couple of different functions, depending upon the type of antigens used. Essentially, it is used for killing cells and/or inactivating toxins. For example, the diphtheria-tetanus-acellular pertussis vaccine is a toxoid vaccine. The toxins produced by the bacteria are what causes illness in humans and what we need antibodies against. The addition of formaldehyde internally cross-links the toxin and also cross-links it to other toxins, effectively detoxifying to eliminate pathogenicity. Viral vaccines such as influenza and hepatitis A vaccines utilise formaldehyde to inactivate viral activity, allowing the recipient to produce antibodies to the antigens without pathogenicity (Aunins et al. 2000).

The actual amount in vaccines is minuscule, even when considering an infant that receives the full CDC schedule. If you look at this table, it contains a list of vaccines and their final formaldehyde content. Not included in this table is Pentacel which contains 0.005mg of formaldehyde. If all vaccines are given as per the CDC recommendation and separately, the most a 2 month old infant would receive is 0.1204 mg of formaldehyde or 120.4 mcg. Going back to what normal formaldehyde levels for a 5kg, 2-month old infant are 1.1-1.2 mg or 0.22-0.24mg/kg so the total formaldehyde exposure from vaccines would raise that to 1.22-1.32 mg or raises the baseline level by less than 1 grain of sand/35 Hummers. Put another way, the amount contained within a vaccine is more than 50 times less than what is in a pear.

Given what is known about human formaldehyde metabolism, excretion and toxic levels, along with what is actually in vaccines, we hope that this gives some perspective about the safety of the amount of formaldehyde that an infant would receive via vaccines. There is simply no valid argument, beyond the scope of fear-mongering that formaldehyde exposure from vaccines is implicated in any health problems, whatsoever.

References:
Aunins JG, Lee AL, Volkin DB. Vaccine Production. In: Bronzino JD, ed. The Biomedical Engineering Handbook 2nd ed. Vol. 2. New York, NY: Springer Publishing; 2000. http://books.google.com/books?id=T2UIoAxcFdIC&pg=PT175&lpg=PT175&dq=&source=bl&ots=J4Skfly-bt&sig=InDm5MbbsfSOztSu5WoeSGAYh7A&hl=en&ei=s938SciZD4TCM6Gi8csE&sa=X&oi=book_result&ct=result&resnum=8. Accessed May 10, 2009:105-8—105-9.

Bosetti C, McLaughlin JK, Tarone RE, Pira E, La Vecchia C. Formaldehyde and cancer risk: a quantitative review of cohort studies through 2006 . Annals of Oncology. 2008; 19:29-43. http://annonc.oxfordjournals.org/cgi/reprint/19/1/29.pdf. Accessed May 10, 2009.

The Children's Hospital of Philadelphia (CHOP). Vaccine Education Center Web site. http://www.chop.edu/consumer/jsp/division/generic.jsp?id=75809. Accessed May 10, 2009.

Clary JJ and Sullivan, Jr. JB. Formaldehyde. In: Sullivan, Jr. JB and Krieger GR, eds. Clinical Environmental and Toxic Exposures. 2nd ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2001. http://books.google.com/books?id=PyUSgdZUGr4C&pg=PA1008&lpg=PA1008&dq=formaldehyde+human+normal+metabolite&source=bl&ots=IJTP64uYmW&sig=jttT7L4_AseC6hm3eVXzUP56hQI&hl=en&ei=Gmv7SfTkJ46UMrvr3dQE&sa=X&oi=book_result&ct=result&resnum=1#PPP1,M1. Accessed May 10, 2009:1007-1008 and 1010.

Indoor Air Quality. U.S. Environmental Protection Agency (EPA) Web site. http://www.epa.gov/iaq/formaldehyde.html. Accessed and link repaired Aug 1, 2012.

Franks SJ. A mathematical model for the absorption and metabolism of formaldehyde vapour by humans [abstract]. Toxicology and Applied Pharmacology. 2004; 206(3):309-320. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WXH-4F7B42G-2&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7617394a3010f1b021e3164141aefec1. Accessed May 10, 2009.

Environmental Health Criteria 89: Formaldehyde. International Programme on Chemical Safety (INCHEM) Web site. http://www.inchem.org/documents/ehc/ehc/ehc89.htm#SubSectionNumber:5.1.4. Accessed May 10, 2009.

Mason DJ, Sykes MD, Panton SW, Rippon EH. Determination of naturally-occurring formaldehyde in raw and cooked Shiitake mushrooms by spectrophotometry and liquid chromatography-mass spectrometry [abstract]. Food Additives and Contaminants. 2004; Nov;21(11):1071-1082. http://www.informaworld.com/smpp/content%7Edb=all?content=10.1080/02652030400013326. Accessed May 10, 2009.

Pandey CK, Agarwal A, Baronia A, Singh N. Toxicity of ingested formalin and its management [Abstract]. Human & Experimental Toxicology. 2000;Jun,19(6);360-366. http://www.ncbi.nlm.nih.gov/pubmed/10962510?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor. Accessed May 10, 2009. PMID: 10962510.

CDC Final Report on Formaldehyde Levels in FEMA-Supplied Travel Trailers, Park Models, and Mobile Homes Web site http://www.cdc.gov/nceh/ehhe/trailerstudy/pdfs/FEMAFinalReport.pdf. July 2, 2008. Accessed May 10, 2009.

Weisel CP et al. Relationships of indoor, outdoor, and personal air (RIOPA). Part I. Collection methods and descriptive analyses [abstract]. Research Report (Health Effects Institute). 2005;Nov(130 Pt 1):1-107; discussion 109-127. http://www.ncbi.nlm.nih.gov/sites/entrez?Cmd=ShowLinkOut&Db=pubmed&TermToSearch=16454009&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation. Accessed May 10, 2009. PMID: 16454009.

IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. World Health Organization (WHO). Volume 88 Formaldehyde, 2-Butoxyethanol and 1-tert-Butxypropan-2-ol. 2006. Web site. http://monographs.iarc.fr/ENG/Monographs/vol88/volume88.pdf. Accessed May 10, 2009.

Cochrane Collaboration on Influenza

I went to a talk given by Sir Iain Chalmers, cofounder and current director of the Cochrane Collaboration yesterday. He spoke about the various controlled trials that need to be performed to ensure that a new medicine is a) effective and b) not doing more harm than no treatment or previously used treatments. He was taking us through the history of treatments for pneumonia (for the longest time treated with blood letting, as late as 1903), treatment and prevention of diphtheria, and prevention of whooping cough and measles. I am hoping the James Lind Library or Public Health Department of Edinburgh University will publish the lecture eventually. For the moment, Evans, Thornton and Chalmers' book "Testing Treatments" , free for download at the James Lind Library is a suitable alternative. But since everyone is talking about the flu, Sir Iain also pointed to the Cochrane Collaboration's new page on all things infuenza and to Dr Tom Jefferson's pod cast that summarizes the findings of all Cochrane Reviews on influenza in a few minutes. Listen in - you may be surprised:

Special Podcast - summary of Cochrane Reviews on influenza

Play Now! | Download [mp3]