Oct 9, 2007 (CIDRAP News) – In quick succession, the view that influenza shots yield life-saving benefits for elderly people has come under serious attack and received fresh support in recent weeks.One group of experts, writing in the October issue of Lancet Infectious Diseases, argued that the mortality benefits of flu shots for the elderly have been greatly exaggerated because of a subtle bias and other methodologic problems in many of the relevant studies.”The remaining evidence base is currently insufficient to indicate the magnitude of the mortality benefit, if any, that elderly people derive from the vaccination programme,” says the analysis by Lone Simonsen, PhD, of George Washington University in Washington, DC, and colleagues.But in the Oct 4 New England Journal of Medicine (NEJM), another team of experts presented a study showing that in the course of up to 10 flu seasons, flu shots reduced the risk of hospitalization for pneumonia and flu by 27% and shrank the risk of death by 48% for elderly members of three health maintenance organizations (HMOs). The study addresses several of the methodologic problems raised by the Lancet authors.”Vaccine delivery to this high-priority group should be improved,” states the report by Kristin Nichol, MD, of the Minneapolis Veterans Affairs Medical Center and University of Minnesota, and four coauthors.The controversy has major policy implications, since the Centers for Disease Control and Prevention (CDC) and other medical groups heavily promote flu shots for elderly people, given their risk for serious complications if they contract the flu. This policy is reinforced by Medicare coverage of flu shots for this age-group.A sharp critique of the evidenceThe Lancet Infectious Diseases authors offer several reasons for questioning the notion that flu immunization saves lives in the elderly population:Vaccination coverage among the elderly has increased from 15% to 65% since 1980, but instead of declining, overall mortality due to pneumonia and influenza in elderly people has increased in that period.Few randomized, placebo-controlled trials have examined flu vaccine effectiveness in elderly people. The largest and best study, done in the Netherlands, showed a 50% reduction in confirmed flu cases among all the volunteers, but the reduction for those older than 70 was only 23%. There was no significant reduction in influenza-like illness.A number of investigators have reported finding evidence of flu vaccination benefits in the elderly by analyzing the records of large healthcare organizations. But these studies typically are flawed in that investigators looked for an effect on all-cause mortality, a nonspecific outcome, rather than on lab-confirmed flu. Further, many such studies may be marred by a subtle selection bias, wherein relatively healthy older people were more likely to be vaccinated than frail seniors were, thereby making vaccination look more beneficial than it really was. A further problem is that cohort studies typically have defined the flu season arbitrarily as December through March, rather than on the basis of flu surveillance.Simonsen and colleagues also write that since 1968, flu has accounted for an average of about 5% of all winter deaths in older people. Yet the results of cohort studies have prompted claims that flu vaccination reduces the risk of winter death from any cause by about 50% for community-dwelling people older than 65. “That influenza vaccination can prevent ten times as many deaths as the disease itself causes is not plausible,” say Simonsen et al.They argue that in view of the “slim” evidence that flu immunization prolongs elderly people’s lives, it may be time to consider doing more randomized, placebo-controlled trials—even though using a placebo would be “ethically unappealing.” In addition, they suggest, other options for protecting the elderly should be pursued, such as developing vaccines that are more immunogenic, using larger vaccine doses, and employing antiviral drugs more aggressively.Meanwhile, the researchers say elderly people should continue to be vaccinated, because “even a partly effective vaccine would be better than no vaccine at all.”Critiquing the critiqueThe review by Simonsen and colleagues drew praise in an editorial in The Lancet, written by two other vaccine experts who have reviewed the case for flu immunization in the elderly. Tom Jefferson and Carlo Di Pietrantonj of the Cochrane Vaccine Fields in Alessandria, Italy, write that Smonsen et al “prove that statistical methods for adjustment for residual bias used in the observational studies of influenza vaccines did not work, largely because of the difficulty of adjusting for frailty with data available in electronic records.”Jefferson and Di Pietrantonj endorse the idea of doing new randomized, placebo-controlled trials of flu vaccination in older people, arguing that such studies are “the only ethical and scientific way” to settle conclusively whether the vaccines are protective. The trials must cover more than one flu season and be large enough to detect rare outcomes, such as deaths due to flu, the pair assert.In an interview, a flu expert with the CDC asserted that the evidence of effectiveness remains strong enough to justify the US policy of promoting flu shots for the elderly. David K. Shay, MD, MPH, a medical officer in the CDC’s influenza division, agreed that better vaccines are needed, but he rejected the idea of doing placebo-controlled trials in the elderly as unethical.Shay said the randomized, controlled trial from the Netherlands that showed a 50% reduction in confirmed flu cases among the elderly provided “gold standard evidence” for a protective effect. The risk was reduced 57% in 60- to 69-year-olds versus 23% in those 70 and older, but because of wide confidence intervals, the difference between the two groups was not significant, he said.The Dutch findings and the high risk of flu-related hospitalization and death in the elderly provide the major underpinnings of the US policy of promoting flu vaccination in the elderly, Shay said, adding, “We’re left with the fact that this study [by Simonsen et al] isn’t going to change policy in the US for the use of these vaccines.”He said it is very difficult to demonstrate a reduction in mortality as a result of vaccination: “No vaccine trial ever done in the developed world has been [statistically] powered to look at a mortality benefit. So we’re going to have to rely on observational data.”As for the suggestion that unmeasured confounding variables have inflated the effectiveness of flu vaccines in observational studies, Shay said, “We also think that’s possible. The CDC is interested in working with HMOs to get a better handle on how to do vaccine effectiveness studies and mortality outcome studies.”But given the existing evidence that flu shots do help protect seniors, he rejected the suggestion of doing placebo-controlled trials. “If you can’t honestly answer, ‘I have no idea’ to the question whether the vaccine is effective, then you have no basis for doing a placebo-controlled trial,” he said.On the other hand, Shay commented, “Everybody would agree that we need a vaccine with greater effectiveness and greater immunogenicity in the elderly. Manufacturers are working on adjuvanted vaccines that hopefully will be more effective.”HMO study addresses methodologic issuesIn the NEJM study, Nichol and associates sought specifically to address the kinds of methodologic problems cited by Simonsen et al. They retrospectively gathered data on flu vaccination, hospitalization for pneumonia and flu, and death from any cause among community-dwelling elderly members of three HMOs. The study covered the flu seasons from 1990-91 through 1999-2000 for one HMO and those from 1996-97 through 1999-2000 for the other two. The HMOs were in Minnesota and Wisconsin, Washington state, and the New York City area.The study included 713,872 person-seasons of observation. Vaccinated subjects were slightly older and had slightly higher rates of most of the underlying medical conditions that were recorded. There were 4,599 hospitalizations for pneumonia or flu and 8,796 deaths.The per-season hospitalization rates for unvaccinated and vaccinated people were 0.7% and 0.6%, and the corresponding death rates were 1.6% and 1.0%. The figures translated into a 27% reduction in hospitalization rate for pneumonia and flu among the vaccinated (adjusted odds ratio, 0.73; 95% confidence interval [CI], 0.68 to 0.77) and a 48% reduction in mortality (adjusted odds ratio, 0.52; 95% CI, 0.50 to 0.55).The vaccine was somewhat less effective in preventing death—a 37% compared with 48% reduction—in the two seasons when the vaccine was a poor match for the circulating viral strains. For the seasons in which there was a good match, the vaccine yielded a 52% reduction in mortality risk.In an effort to detect any “healthy-vaccinee bias” (better underlying health among the vaccinated than the unvaccinated), the authors compared the risk of hospitalization among vaccinated and unvaccinated subjects during the summers (noninfluenza seasons) of 1999 and 2000. They found that the risks were similar for the two groups.The researchers went a step further by hypothesizing that an unmeasured confounding variable was influencing their findings and then estimating what that influence would be under various assumptions. They picked functional status as the unmeasured variable most likely to affect their subjects’ risk of hospitalization or death.On the basis of studies of functional status, the authors estimated that subjects with poor functional status would be half as likely to get a flu shot and two to three times as likely to be hospitalized or die, compared with those with better functional status. When they plugged these estimates into their data, along with estimates of the prevalence of the confounding variable, they found that the effectiveness of vaccination was reduced but still significant.For example, assuming that the confounder was present in 60% of subjects and that it doubled the risk of hospitalization or death, vaccination still reduced the risk of hospitalization by 14% and the risk of death by 39%. In the most extreme scenario—the confounder was prevalent in 60% and tripled the risk of hospitalization or death—vaccination still lowered the risk of hospitalization 7% and the risk of death 33%.The researchers write that their study “showed multiple benefits across multiple subgroups, a result suggesting that vaccination benefits probably extend to a broad spectrum of elderly persons.” However, they acknowledge that elderly HMO members may differ from elderly nonmembers, and the study did not include the frailest elderly, such as those living in nursing homes, who are likely to have weaker immune responses.A confidence boosterIn an accompanying NEJM editorial, John D. Treanor, MD, writes that the study by Nichol et al addresses many of the concerns raised about other observational studies “and increases our confidence in the benefits of influenza vaccination in older adults.”Because the evidence of vaccine effectiveness held up well through 10 seasons, the findings “convincingly dispel concerns that the previous studies were artifacts of a specific influenza season or a specific population,” states Treanor, who is a vaccine researcher; professor of medicine, microbiology, and immunology at the University of Rochester; and member of the CDC’s Advisory Committee on Immunization Practices.He also comments favorably on the authors’ efforts to address the concerns about unmeasured confounding variables, including the examination of summer hospitalization rates and the estimate of the effect of a hypothetical difference in functional status.”Overall, this study provides additional support for the current strategy to vaccinate elderly adults,” Treanor asserts. The methodologic issues are important, and the precise magnitude of the benefits of vaccination is not yet clear, but it is clear that vaccination is beneficial and should be used widely, he adds.However, he agrees with Shay that the development of more immunogenic and effective vaccines for the elderly is an important goal.Shay said the CDC is contemplating a special initiative to help resolve the controversy over the value of flu immunization for seniors. “Sometime in 2008 the CDC hopes to get together a panel of consultants to bring about ways to move forward and find ways to resolve this controversy,” he said. By assembling experts from the different camps, the agency hopes to come up with recommendations to guide the next series of studies, he said.Simonsen L, Taylor RJ, Viboud C, et al. Mortality benefits of influenza vaccination in elderly people: an ongoing controversy. Lancet Infect Dis 2007 Oct;7:658-66 [Abstract]Jefferson T, Di Pietrantonj C. Inactivated influenza vaccines in the elderly—are you sure? (Editorial) Lancet 2007 Oct 6;370(9594):1199-1200Nichol KL, Nordin JD, Nelson DB, et al. Effectiveness of influenza vaccine in the community-dwelling elderly. N Engl J Med 2007 Oct 4;357(14):1373-81 [Full text]Treanor JD. Influenza—the goal of control. (Editorial) N Engl J Med 2007 Oct 4;357(14):1439-41 [Full text]
State-owned tin miner PT Timah is slated to invest around Rp 2 trillion (US$145.6 million) to finance expansion projects this year, including the construction of a tin smelting plant.Timah corporate secretary Abdullah Umar Baswedan said in Jakarta on Monday that the funds would be partly used to finance the exploration of new tin reserves on the tin-rich Bangka Belitung Island.Investment would also go into developing an US$80 million smelter in the province, repairing old ships, growing company subsidiaries and continuing exploration efforts in Africa, he added. Topics : The publicly listed miner has yet to publish its annual report for the 2019 financial year but Abdullah estimated that production reached between 65,000 and 70,000 tons last year. This year, production is projected to increase 5 percent. But revenue during the year would rely much on global tin prices, which have begun to decline since January due to the coronavirus epidemic in China, the world’s largest tin consumer.“We cannot control global prices. But we can control and maintain our export volume,” said Abdullah, adding that Indonesia contributed 23 percent of the global tin market, “If we exclude China, it’s more than 40 percent.”Timah president director Mochtar Riza Pahlevi Tabrani, also on Monday, said the company was looking into exploring mineral reserves in Nigeria and Tanzania. The company was particularly close to beginning operations in the former, where it only needs “a sort of environmental impact assessment” to begin.“The biggest challenge in Africa is limited infrastructure,” he said, “The second issue is security.”
The price of medium quality rice is averaging Rp 10,202 per kilogram, about 8 percent higher than the retail price ceiling (HET). The price of unhusked rice is Rp 4,977 per kilogram, 17 percent higher than the government’s reference price (HPP).“We hope the government will give a stimulus for additional funds to buy husked and unhusked rice,” Tri said in an online discussion on Wednesday. “With the government’s permission, we will propose it at the limited coordination meeting so that Bulog can get the opportunity to buy as much as it can above the HPP.”The government has asked the agency to raise stocks of basic commodities to control the rising staple food prices, including rice, to anticipate both surging demand during Ramadan and Idul Fitri and logistical disruptions due to large-scale social restrictions (PSBB).Between March and May, the Agriculture Ministry estimates the demand for rice will total 7.6 million tons. The rice harvest reaches its peak in April, and production is expected to exceed demand by 8.3 million tons by the end of May. The State Logistics Agency (Bulog), a governmental body responsible for securing the staple food supply, plans to ask for an additional Rp 10 trillion (US$637 million) from the government to buy rice from farmers to augment rice stocks.The agency’s director of operations and public service, Tri Wahyudi Saleh, said in Jakarta on Wednesday that the extra funds would be enough to procure about 1.2 million tons of rice from the farmers.Tri said that the increase in prices of milled rice and unhusked rice would make rice procurement more costly. With the high price, the procurement would be too costly if the agency had to borrow from banks, he added. However, consumption tends to rise by 3 percent in the period leading up to Ramadan, set to take place on April 23, and by 20 percent leading up to Idul Fitri on May 24, according to a survey by the Agriculture Ministry’s Food Security Agency. Bulog’s sales usually rise by 10 percent over the period.The introduction of large-scale social restrictions in Greater Jakarta, considered the nation’s COVID-19 epicenter, may pose a challenge to the government’s plan.“We have prepared a banner for Bulog logistics [shipments] saying that the goods inside belong to the agency,” said Tri. “This was very helpful when we distributed sugar and rice from Lampung to Jakarta. We were prioritized by the ASDP [state-owned ferry operator] and we were escorted by the local police traffic unit.”The Jakarta and West Java administrations have suspended public activities and have imposed limitations on transportation for 14 days until late April to slow the spread of coronavirus.As of Tuesday, Jakarta, which accounts for about 20 percent of the national rice market, had confirmed 2,335 cases of COVID-19 – nearly half of the total confirmed cases nationwide.Not all staple food supplies are distributed by Bulog. As private retailers also take part in the distribution of staple food, they should maintain product quality despite logistical disruption due to the government’s measures to contain the fast-spreading coronavirus, said Center for Indonesian Policy Studies researcher Galuh Octania.“Even before the introduction of large-scale social restrictions, some distributors complained about delays,” Galuh said in the same online talk on Wednesday. “The shipment of food commodities usually takes a day, but it was delayed by up to three days for various reasons, such as drivers’ reluctance to work or fear of getting stopped [by authorities].”Topics :
CENTURIES from Leon Johnson and Chandrapaul Hemraj helped to ease Guyana Jaguars into a comfortable state of mind going into next week’s start of the Regional 4-Day Tournament.The national team wrapped up their training yesterday at Providence with the last of their two practice games. Looking to bat for longer periods, the players of the Johnson XI used the two days instead of three to up their scoring as they racked up 388-5 at the end of stumps.Batting one minute shy of 200 minutes, Hemraj lit up the stadium with 8 sweetly-timed fours and six massive sixes as he warmed up for the Regional 4-Dayers with a stylish 104.He shared a whopping 167-run second-wicket partnership with his national captain Johnson who broke his run drought with an identical score of 104.The Jaguars captain batted for more than 300 minutes for his century which was decorated with 9 fours and a six before he retired, allowing the other players to have some time.Tagenarine Chanderpaul also batted himself into some form with his solid 51 at number 4. Chris Barnwell also looked good for his 27 as the Jags premier players had good periods with the bat.Resuming just four runs shy of a half-century, Hemraj reached his first milestone in a casual manner. The Test opener’s confidence grew, as he found scoring easy and despite his aggression he managed to negate the good deliveries while feasting on the bad ones.His hundred came in grand fashion as he clobbered Ricardo Adams’ spin for a maximum which he celebrated with his skipper.Johnson, meanwhile, grafted a much-needed innings together; his timing and temperament seemed to be coming back as he reached his fifty.Soon after the duo’s celebration, tragedy struck as Alimohamed broke the edge of the centurion, to which keeper Kemol Savory made no mistake in collecting.After Johnson’s retirement, Chanderpaul continued to wear out the opposition’s bowling on his way to 50, topping off a strong performance for the batsmen. (Clifton Ross)
Braves’ Sean Newcomb has meltdown, sets off fire extinguisher after blown lead #Braves Claim OF Billy Hamilton off Waivers: pic.twitter.com/9nD3UUllsU— Atlanta Braves (@Braves) August 19, 2019Hamilton signed a one-year contract with the Royals this offseason. He hit .211 and stole 18 bases in 93 games with the team. Hamilton spent the first six years of his career with the Reds, where he batted .245 and swiped 50 or more bases in four straight seasons from 2014-17. Related News The Braves, meanwhile, placed outfielder Ender Inciarte on the injured list last weekend with a strained hamstring. He’s expected to miss four to six weeks. “I just want to do whatever it takes to fully be back to 100%,” Inciarte said after suffering the injury, via The Atlanta Journal-Constitution. “Right when I did it, I knew I was going to miss some time. I’m in pain right now. I’m just hoping it gets better soon.”Inciarte, who is slashing .246/.343/.397 with five home runs and 24 RBIs in 65 games in 2019, said he hopes to return before the end of the regular season, but that is far from a guarantee. The Braves have added depth in their outfield.Atlanta claimed speedster Billy Hamilton off waivers Monday, the team announced. The 28-year-old was designated for assignment by the Royals last week. Braves turn to Mark Melancon as closer Braves’ Ronald Acuna reacts to being pulled from game for not hustling It looks like Ender Inciarte suffered an injury scoring from second.Stay tuned. pic.twitter.com/ysnzYc3cog— FOX Sports: Braves (@FOXSportsBraves) August 16, 2019“We’re still going to play in October, and I want to be part of that,” Inciarte said. “In my mind, I’m thinking like that. … I have to be 100% positive that I’m coming back and that this team is going to be in a good position by then, and that we’re going to compete and do well in October because that’s the goal.”The Braves entered play Monday in first place of the National League East with a 74-52 record. They lead the Nationals by 5 1/2 games.
Johnson is able to return to racing this weekend because he has tested negative for COVID-19 twice this week, once on Monday and once on Tuesday. NASCAR requires two negative tests at least 24 hours apart before a person in the sport who tests positive can return.“My family is so grateful for the incredible love and support we’ve received over the last several days,” Johnson said in a team release. “I especially want to thank Justin Allgaier for stepping in for me at Indy and being a true pro. I’m excited about getting back to business with my team this weekend.”Johnson, who was the first NASCAR driver to test positive for COVID-19 since the sport’s return to racing in May, never experienced any symptoms of the virus. Johnson said Barban’s support video, which appeared to be filmed at Indianapolis Motor Speedway last weekend, was “too good not to share.” We’ll have to agree to disagree.It’s been an emotional journey and I’m so happy to be back. Thank you for all the support. This video was one of my favorites and is too good not to share, courtesy of @bigearl48. See you soon @kyspeedway. pic.twitter.com/zFSJiPN2V0— Jimmie Johnson (@JimmieJohnson) July 8, 2020MORE: Updated 2020 NASCAR scheduleIt’s unclear whose voice recorded the cringe-worthy rap, but the culprit of the lyrics seems to be Barban himself because of the line, “I’ll do good for (Justin) Allgaier,” who ran the Indy race in Johnson’s place but crashed out early and finished 37th. Below are the lyrics.”To our brother Jimmie, sure miss you at Indy.”We wish our boy was here, but since you’re not, enjoy a beer.”I’ll do good for Allgaier, but if I say I like it, I would be a liar.”Kick this WuFlu in the ase, so you can get back here and race.”Oof. At least Barban ended the video on a positive note with a message of care to Johnson and his family as they navigated a difficult scenario. Surely, Jimmie Johnson shared a video of a dancing Earl Barban on Wednesday with good intentions and with permission from his Hendrick Motorsports spotter. But a simple “I’m back” would have sufficed.Johnson, who was cleared Wednesday to return to racing after testing positive for COVID-19 and missing last week’s Brickyard 400, confirmed his status for Sunday’s race at Kentucky Speedway and, obviously unknowingly, embarrassed his spotter in the process.