When a kid is too sick for school, as a parent, what do you do? Do you miss work to stay home and care for your child? Lean on a spouse or relative for help? Or, is bringing your kid (that’s recently fallen ill) into the workplace -with you- a feasible option? After all, the show must go on. Am I right?

This is on my mind because my friend and coworker (a single mother of four) was recently confronted with this very predicament. Interestingly, as I watched her cautious attempts to navigate each of her limited options, it’s what I encountered personally that sparked a fire of curiosity inside me — a flame I quickly learned I alone was not yet equipped to extinguish. It was this faint flicker which lead me headfirst into the heated flu shot debate… A hot topic I’d somehow managed to evade my entire adult life. Until now.

THAT’S RIGHT, I’ve never had a flu shot.
It’s not that I haven’t entertained the thought of getting one. I have. In fact, each year when public health initiatives billboard and national drug stores campaign for the benefits of flu shots for the masses, I find myself thinking, “Hey, maybe I should”. After all, I have been working for a county commissioner (and self-proclaimed germophobe) long enough to know that he’d appreciate my taking one for the team (i.e., a shot in the arm) once a year before flu season. [If interested, you can even watch the man (County Commissioner Mark Christensen) receive his annual flu shot in a vid clip that can be viewed on the Campbell County Local Government Facebook page.]

About Mark: He’s a husband and father who largely advocates in favor of immunizations.

About Me: I value his opinion.

While I admire his commitment to progressive community causes, such as wellness and flu prevention, among others, I can be stubborn and oftentimes shy away from change. For these and other reasons, including the stigma surrounding influenza immunizations, I’ve simply chosen to forego flu shots altogether, taking our fearless leader’s annual encouragements to vaccinate at face value as optional.

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In previous years though, I can remember thinking, “Why would anyone spend their valuable time and money (even a measly $25) for a shot that’s so controversial? Especially if it’s not required!”

I brought these and other questions to a handful of healthcare professionals at the Wyoming Health Department (WHD), Campbell County Health (CCH), and Campbell County Public Health (CCPH), including the local public health office’s Executive Director Jane Glaser, RN, and WDH Public Information Officer (PIO) Kim Deti, among others. And, now I’m beginning to wonder… Has the “if it ain’t broke, don’t fix it”-mentality somehow failed me? Or perhaps, more regrettably, am I failing those whom I care most for?

What I’d like to share with you are my findings and observations resulting from hours of research following some lengthy and heated conversation with health care professionals at local and state levels. But, before heading too far down the rabbit hole, let me be clear in saying that my aim is not to advocate either for or against vaccination for you and your family. Instead, I’ll be presenting information I found value in learning and knowing. I recognize this issue is not simply black and white. I also respect and understand that the important decisions you make regarding your health and the health of your family are yours alone. With that in mind, I humbly offer my thoughts on the supporting arguments from both sides of the influenza immunization fence. But, first things first.

The face of influenza

Let’s take a big sidestep away from the matter at hand (what’s a single mum to do when one of her flock falls ill and is unable to attend school), to better understand the scope and scale of what I believe to be the real problem. And, yes. It’s a problem. In fact, it’s my firm belief that this problem actually stems from a much greater — although entirely different — problem. Stick with me, folks. We’ll circle back.

Influenza (or, the flu) is a highly contagious respiratory disease caused by a viral infection that attacks the nose, throat, and lungs. Each year, the flu infiltrates the community like a wildfire, spreading via little, often invisible, droplets of virus-infected fluids (think bitsy blops of yucky mucus and phlegm) that are made when someone infected with the flu coughs, talks, or sneezes. The virus then spreads when the next person comes into contact with the infected bits of fluid.

Not to be confused with the common cold, flu symptoms tend to develop more rapidly and are usually noticeably more severe than the typical coughing, sneezing, and congestion commonly associated with a regular cold. Flu symptoms can include sudden or excessive fatigue, body aches and chills, cough, sore throat, fever, and gastrointestinal problems like diarrhea, nausea, stomach pain, or vomiting. Flu symptoms specific to children can also include not wanting to drink fluids, tearless crying, lack of appetite, fever accompanied by rash, difficulty urinating, and not waking up or interacting with others. According to the U.S. Centers for Disease Control and Prevention (CDC), unlike the common cold, flu can cause mild to severe illness and, at times, can lead to death.

It’s not that serious

Or, is it? Let’s rewind. According to CDC, unlike the common cold, flu can cause mild to severe illness and at times can lead TO DEATH. CDC estimates that in each year since 2010, the flu has resulted in over 9.2 million reported illnesses, up to 710,000 possible hospitalizations from flu-related complications, and somewhere between 12,000 and 56,000 deaths in the U.S. Again, these numbers are representative of annual CDC findings from CDC.

“The flu results in approximately
12,000 to 56,000 deaths each year
in the U.S.” ~ CDC

We, the public, can conclude from CDC numbers that between 5 to 20 percent of the population contracts the flu each year. But, is it just me? Or, are things being made to sound as though an awful lot of Americans are infected and dying from flu? Is almost a quarter of the U.S. population actually at risk of contracting this potentially deadly virus each year? These are scary statistics. Sadly, I believe that’s the point. I’ll admit that when I first read that flu results in up to 56,000 deaths a year, I took to my smartphone to Google where I could find the nearest and most affordable flu shot, and fast. But, then I realized, I don’t actually know anyone who’s died from flu. Do you?

Digging deeper

Let’s take a closer look at the specific language CDC uses to depict its interpretations of the flu’s annual impact. What’s with the range variance? Because, there’s a big difference between 12,000 and 56,000 dead. While they say the impact of flu can vary, CDC also calculates what they call an “annual range of influenza and influenza-related death estimates”. Meaning, at CDC, they keep a tally of how many die from flu each year. And, according to its website cdc.gov, CDC determines its range of flu death estimates by using reports of pneumonia and influenza (P&I) deaths and reports of respiratory and circulatory (R&C) deaths attributable to influenza. Stay with me, now.

On the website, it states that P&I deaths are available in real-time, while R&C deaths are only available following a three-year delay (although no reason for the R&C delay or its three-year holding period are listed). The site does state that, “While both estimates (P&I and R&C deaths) are useful, P&I deaths represent only a fraction of the total number of deaths from influenza because they do not capture the deaths that occur red among people not tested for influenza or deaths that result from respiratory and cardiovascular complications. Calculations based on R&C deaths are used in CDC influenza-related communications materials because these calculations provide a more complete estimate of the actual burden of influenza.”

In summation, it appears to me as though each year CDC estimates a blanket approximation of deaths in the U.S. caused by flu. They use two sources to do this; let’s call those “Source A” and “Source B”. CDC says they use these sources to guess approximately how many deaths may have been caused by the flu during any given year. Except, Source A can’t account for deaths that aren’t accounted for (even if it does include countless other deaths caused by an entirely different illness altogether). For this reason, CDC says they only use calculations from Source B for their marketing materials and efforts (what we, the public, see and read). Again, Source B includes reports of respiratory and circulatory deaths “attributable to influenza”; not influenza deaths.

Lung cancer, a leading cause of death for both men and women in the U.S., is an example of a respiratory death. No quantifications for what constitutes a death as “attributable to influenza”, are listed (for R&C deaths or any other type of death) on the website.

Que the skeptics

Here’s what (we think) we know. We are told that the flu vaccine is essential for protecting our children against influenza. In 2009, CDC expanded its annual flu shot advice to include mostly everyone over six months old. And presently, CDC recommends that everyone six months and older receive an annual vaccination, unless otherwise instructed by a healthcare professional. Most health officials agree, too —urging the vast majority of us to get annual flu shots, excluding only newborns and those who have experienced a life-threatening allergic reaction to an influenza vaccine or vaccine component.

The idea is that when more people in a single community receive the flu vaccine, less flu viruses can spread there, and those viruses that do spread have decidedly shorter lifespans with reduced and shorter-lived symptoms (resulting in less absences from school and work). And, according to CDC, for decades tests have supported this notion suggesting that the flu vaccine not only worked, but worked extremely well. Yet, with so many viruses and strains circulating, as reported in the state department’s 2016-17 Wyoming Influenza Report, “It’s a yearly challenge for scientists to predict which three or four vaccines will adequately provide the best protection against the season’s most prevalent and potent flu viruses.”

Poor scores

Health and Human Services Secretary Dr. Thomas Price, a panelist at this year’s National Foundation for Infectious Diseases (NIFD) press conference, which occurred in Washington, D.C, this September, admits flu vaccines aren’t perfect. And, according to a Forbes Pharma & Healthcare article by Rita Rubin who wrote on Price’s appearance at the junket, Price also said that flu vaccines are only 40 to 60 percent effective; fact supported by the CDC website.

If the effectiveness of flu shots were rated on a rank-based grading scale (for example, a letter scale from A to F), it’d fail across the board. Yet, states continue to push flu shots. Why is that? The fact that flu vaccines aren’t 100 percent effective does discourage some people from bothering to get them, says Rubin in her article. However, even if you still contract the flu after getting immunized, according to Rubin, research suggests that it is likely to be a milder strain than if you hadn’t been immunized. No research was sourced in her article.

Despite flu shot ineffectiveness, CDC and public health officials continue to endorse flu shots for all with a national vaccine plan that’s grown to include almost everyone from cradle to grave.

 

Big pharmaceutical’s role

So, do the arguments that flu shots are merely a well-oiled money-making machine, have merit? Perhaps. Flu vaccine is produced independently by private manufacturers who innately determine market supply and demand. Those manufacturing and profiting from the production and sales of flu shots internationally, include: Sanofi, GlaxoSmithKline, Novartis, AstraZeneca unit MedImmune, and CSL. Of those, French multi-national pharmaceutical powerhouse Sanofi is the world’s fifth-largest by prescription sales with over 4.8 billion euro in 2016 profits. Additionally, Sanofi is the world’s largest producer of vaccines through its subsidiary Sanofi Pasteur, which makes Fluzone® Quadrivalent Influenza Vaccine, among others.

Non-manufacturing groups who’ve seen increased profits resulting from the highly lucrative annual flu immunization business are U.S. drugstore chains like Walgreen and CVS/Caremark Corp., who have each experienced multi-million dollar sales gains in every year since Fall 2009, when several states began allowing pharmacists to administer seasonal flu and H1N1 (swine flu) vaccines.

Despite an aggressive awareness campaign, trending in recent years to increase the number of people getting flu shots, CDC say still far too many people are not getting vaccinated. However, charts tracking distribution quantities between 1980 and present day display off-thecharts increases in dose distribution, from 12.4 million in 1980 to 130 million each year since 2010. You can view them here: https://www.cdc.gov/flu/professionals/ vaccination/vaccinesupply.htm.

What’s the big deal?

Last year, WDH reported 15 flu-related deaths during the 2016-17 flu season, from Oct. 2, 2016 to May 20, 2017, although mostly among older residents. Last year, CDC reported 209 deaths attributed to influenza and pneumonia in the State of Wyoming during the 2016-17 flu season, also mostly among older residents. Although the difference in reported deaths between agencies are likely attributable to the inclusion of pneumonia deaths in CDC totals, both agencies also state that neither entity tests for flu in the case of every death, resulting in numbers that cannot be exact.

An October press release from the WDH states that the flu had already been reported in certain pockets of the state as early as October this year. During the week of Oct. 8 – 14, for example, CDC classified Wyoming as having sporadic flu cases. And, during the week ending on Oct. 21, at least 25 confirmed cases had been reported statewide. As a result, unlike years past, our local and state health officials are encouraging almost everyone in Wyoming to get a flu shot this year, and as early as possible.

When 82717 asked WHD PIO Kim Deti if she vaccinates for flu, she said, “Yes, I do. And, so do my children. I want the protection flu shots offer.” In an email, Deti said, “I believe people take flu for granted because it’s familiar, but it can be a serious disease. Most people who become ill are miserable for a few days and miss work or school, but are able to bounce back. But other people are more vulnerable. Every year we see deaths and hospitalizations due to influenza.” When asked for details regarding the Fluzone® Quadrivalent influenza vaccine administered to schoolkids in Campbell County through the local VIP (Vaccines for Influenza Prevention) Program this year, and if those specifics were made readily available to parents and the public on the WDH website, or the website of any Wyoming Public Vaccine Program Provider located here in Gillette, Deti said, “There are several vaccines offered each season. The one you are asking about is manufactured by the Sanofi Pasteur company and includes protection for four different strains of flu considered most likely to be circulating in North America this season.”

The change up

Here’s where things get interesting. Because, much like the inaugural issue of this publication that you’re holding right now, this story, like every truly good story, has a flip side. And, if you’re anything like me, it’s about to blow your mind. And, away we go!

As of June, a total of 101 flu-associated deaths in children occurring during the 2016-17 season had been reported to CDC. While influenza-associated pediatric deaths became nationally reportable back in 2004, since then the number of deaths reported to CDC has ranged from 37 (2011-12 season) to 171 (2012-13 season). Last year, however, was the first time since 2014- 15 that the number of reported pediatric deaths exceeded 100.

“Parents, if there was ever a year to make cold and flu prevention your number-one priority, this is it.” ~ Parents Magazine
In recent years, Campbell County School District (CCSD) has reported over 400 students as being absent from Campbell County Schools each year due to influenza and influenza-related illness during any given year’s respective flu season.

How can you help protect your child and the community from flu?

Thanks to a community health outreach program, funded in part by Campbell County, protecting your children from flu is as easy as one-two-three. One: Check for your child’s immunization release form to be sent home from their school. Two: Sign it. Three: Return it to the school.

VIP (Vaccines for Influenza Prevention) Program

As the result of markedly-coordinated efforts provided for by the VIP Project Committee of the Campbell County Healthcare Foundation (CCHCF), and in partnership with Campbell County Health (CCH), the CCSD, Campbell County Health Department (CCHD), and Campbell County Public Health (CCPH) through community donations and corporate sponsorships, the VIP Project — which came into fruition following a community needs assessment in 2013 which proposed that increasing the number of children receiving flu shots in Campbell County could significantly improve overall community health — results in fewer absences from school, and fewer parents, guardians, and family members getting sick or staying home with sick children.

During the 2015-16 school year, Campbell County donors gave over $60,000 for the project to purchase injectable vaccine for 2,000 children attending Campbell County schools, including the YES House and John Paul II Catholic School. Program investors include: CCH, Cloud Peak Energy, Prevention Management Organization of Wyoming, Coalition Board (of Peabody Energy, Cloud Peak Energy, and Alpha Coal), Sports Screening Committee, Gillette Energy Rotary, Gillette Rotary, First Interstate Bank, Campbell County, and Basin Electric Power Cooperative.

That year, the project traveled to every school in the district (21 in total) with CCPH nurses administering vaccine to approximately 2,200 students, using the Kid Clinic’s mobile unit. Last year, 2,450 vaccines were given through the project, representing a 10 percent increase from the previous year, according to Public Health Exec. Dir. Glaser. This year, 2,650 children signed up for the program. Now, that’s a lot of free shots! Shots administered during school hours; saving Campbell County working parents an average of over $160,000 a year in potentially missed wages. Few communities are so lucky as Campbell County, and on such a widespread level, to receive such awesome opportunities for and access to free vaccinations such as this.

Our county cares

The most recent Wyoming Influenza Summary Report states that influenza activity was moderately severe as determined by the number of influenza-associated deaths, the number of laboratory-diagnosed influenza cases, and the percentage of visits to outpatient clinics or hospitals for influenza-like illness during the 2016-17 flu season. And, systematically immunizing school kids can help.

Studies show giving flu vaccines to as many school-age children as possible, by delivering it at school, for example, can help protect an entire community from flu. Researchers lead by Dr. W. Paul Glezen at Baylor College of Medicine created a study in which the flu vaccine was offered to elementary school kids in eastern Bell County, Texas. Almost 48 percent of the children were vaccinated to reduce flu outbreak and reduce absences from school and work, thus increasing, or at least maintaining, regular levels of health and productivity county-wide. Glezen’s study found that systematically immunizing school kids helped everyone in the community except people in the 12 to 17-year-old age group.

Herd immunity mentality

Needle phobia (or a fear of shots) and trypanophobia (a fear of injections) are very real conditions. In fact, up to 20 percent of people in the U.S. self-identify with either one or both terms. These same individuals admit to avoiding doctor’s offices and preventative healthcare measures as a result of their fears. But, studies show that when a certain percentage of the population can be vaccinated against a virus, such as the flu, a “herd” immunity is created that keeps the virus from circulating widely. Meaning, the weaker of our flock are theoretically hurting our chances of reduced illness by foregoing vaccination.

“The theory is that, for diseases passed from person to person, it is more difficult to maintain the infection when large numbers are immune.” ~ Dr. Lewin
 In essence, the more who are immune, the lower the chance that a susceptible person will come into contact with an infectious one. In a commentary on his study, Lewin describes school children as “centrifugal spreaders” of the flu. Which makes sense, because kiddos have the highest attack rates, the worst hygiene habits, and can excrete the vaccine longer before becoming and after being sick. According to Lewin, targeting school-aged children is a logic-based approach. But, I’d be willing to go one further. Initiating commonplace annual immunizations for children could also potentially mitigate both needle phobia and trypanophobia for future generations, resulting in increased voluntary immunization amongst various groups, or “herds”.

Don’t be a cow-herd

As a parent, according to Lewin’s findings, if you choose not to vaccinate, you not only miss the opportunity to protect your child but you’re also putting others at risk, including: your family, friends, coworkers, employers, etc. [Not to mention, everyone else that both you and your child routinely come into contact with during flu season (because, even if you don’t experience symptoms, you could be infected and serve as a courier of the virus to others, albeit unknowingly)]. For example, think about your child’s teachers and classmates, your server at your family’s favorite restaurant, a grocery store cashier, or the barista at Starbucks, and so on. Even healthy people can get very sick from the flu and pass it on to others. More vaccines can mean more protection, especially for those who are most vulnerable to complications resulting from flu, like those who are very old, very young, or have compromised immune system.

For your reference, Lewin’s study and commentary appear in the December issue of the Journal of Infectious Disease.

Other primary influencers

More healthcare workers are getting vaccinated as more states pass laws making flu shots mandatory. From 2000 to 2005, only two states in the U.S. had flu vaccine requirement laws for health care workers. Those states were Maine and New Hampshire. During that time, according to a study funded by the Robert Wood Johnson Foundation Public Health Law Research program at the University of Pittsburgh, approximately 22.5 percent of health care workers received the flu shot nationwide. From 2006 to 2011, when another 19 states passed similar legislation, the average vaccination rate for health care workers in the U.S. rose to over 50 percent.

In the Journal of the National Medical Association, Richard Zimmerman, a professor of family medicine at Pitt, says, “By getting immunized against the flu, the health care worker is, in essence, building a fence to protect patients, who perhaps can’t get immunized or whose immune systems are so compromised that the vaccine isn’t as effective.” Since its publication, the advisory committees of numerous organizations, including the CDC’s Committee on Immunization Practices, have recommended that everyone over 6-monthold, who is able, including all health care workers, receive annual flu vaccine to reduce the spread of flu and decrease absenteeism in schools and the workplace.

Campbell County Health Infection Prevention Department Community Relations Specialist Dane Joslyn tells 82717, “CCH requires and provides free annual influenza vaccines for all employees, adult volunteers, and physicians.” We (CCH) consistently vaccinate 95 percent or more of our employees every season, Joslyn says.

Fluzone® Quadrivalent

Fluzone® Quadrivalent is the flu shot made available to students of the Campbell County School District (CCSD) through the Campbell County Healthcare Foundation’s VIP (Vaccinations for 42 NOVEMBER / DECEMBER 2017 Influenza Prevention) Project this year. The project has been vaccinating students in the CCSD, with parental consent, since the program’s inception in October 2015.

Here are some highlights from a multitude of information I found on Fluzone®, which helped me in making my decision about whether or not to vaccinate myself and/or our children. Fluzone® is typically administered in a single dose by intramuscular injection, and comes in three versions that are thimerosal-free. It is designed to help protect people 6 months of age and older against 4 different flu strains: 2 influenza A viruses and 2 influenza B viruses, according to the manufacturer’s website. Fluzone Quadrivalent, Fluzone Intradermal Quadrivalent, and Fluzone High-Dose vaccines should not be administered to anyone with a severe allergic reaction (e.g., anaphylaxis) to any vaccine component, including eggs, egg products, or thimerosal (the multi-dose vial is the only presentation containing thimerosal), or to a previous dose of any influenza vaccine. It takes time for the Fluzone® vaccine to work properly, making it ideal to get you and your nuggets to get your flu shots as soon as possible. According to Sanofi, receiving your flu shot before the virus circulates helps you to be protected at the peak of the season. Fluzone® is a split-virus vaccine that is produced by chemical disruption of the influenza virus. Therefore, it is incapable of causing influenza. The 2017-18 vaccine includes two A strains — H1N1 (Michigan), H3N2 (Hong Kong) and also two B strains — Brisbane and Phuket. The information statements regarding this year’s vaccine was sent home with the permission slips from the project through the school district. In January 2011, the FDA recognized that 36 children from 6–24 months old had fevers and seizures within a day of the Fluzone® vaccine. Nasal mist vaccines are no longer recommended, nor available. And lastly, no U.S. federal vaccination laws exist, but all 50 states in the continental U.S. have laws requiring children to be vaccinated against tetanus, polio, measles and rubella (but, not influenza).

Herein lies the problem

Now, let’s circle back to the beginning, where this all got started. What’s a single, working mom to do when one of her kids is too sick to attend school? Must she lean on someone else for help, miss work to tend to her cherub at home, or is bringing a sick kid into the office an option? Obviously, the industry in which the mom works will play a role in how this question’s answered. I also believe that it’s a workplace culture thing. How cool is your boss? How valuable are your daily contributions to the functionality of the team and your place of business? Is another trained to maintain your position in your absence? Do you have someone else who can help you out? Should you rely on someone else to care for your kid? The answers to these questions will probably rely heavily upon your ethics and belief systems, and will vary from person to person. But, if we all ask these questions of ourselves, I believe understanding for others when a co-worker is faced with making this decision.

The bigger problem Of the countless decisions today’s parents face, few that I’ve encountered in my 32 years, are as controversial as whether or not to vaccinate. We’re a community divided.

Which lends to what I believe to be the real, greater problem surrounding flu shots. We’re not all unaware. We’re just fed so many different strains of conflicting information that the decision to vaccinate can become more emotionally charged than reason and fact-based. We understand that where we source our facts from matters. But, who’s telling us the truth? Suzie said she got sick from getting a flu shot last year. We love and believe Suzie. But, at the same time, CDC says shots are safe and pharmaceutical manufacturers make claims that it’s impossible to contract flu from the inactive viruses used in their products. Who, then, can we believe when we’re being fed different truths?

And, how do you keep yourself and your family from contracting influenza this flu season in a community that’s divided, where some do and others don’t vaccinate?

It’s your health. Your family. Your choice.

For those parents, still on the fence, I implore you to educate yourselves further. Find alternative resources, read counterarguments, and ask the hard questions before deciding for yourself. Because, while it’s undeniably true that we haven’t seen a recent outbreak of polio or smallpox in America, we have seen an increase in childhood allergies, behavioral and learning disorders, chronic illnesses, Autism, Asperger’s Syndrome, and SIDS, among several other highly-concerning conditions and illnesses. Now, that’s not to say the above are either loosely nor directly correlated to influenza vaccine or any other vaccinations.

Parents can help prevent and slow the spread of flu in Campbell County by promoting hand washing, covering one’s mouth when coughing, and continuously disinfecting shared surfaces. When children are healthy, they can go to child care or school, and parents can go to work. But, when you or your child are ill, staying home from work or keeping them home from school and work can help prevent flu from spreading. Staying hydrated, and practicing a healthy lifestyle are also great ways to prevent the onset of flu.

The flu vaccine is available at the Public Health office in Campbell County, located at 2301 South 4J Road. The cost of the vaccine at the department is $25, and the service is covered by most health insurance policies. Uninsured persons may inquire with CCPH for Vaccines for Uninsured Adults (VUA) eligibility. The following are local vaccine providers that can be found on the WDH website.

82717 heaven

How blessed are we to live here in the 82717 where we can not only choose what’s best for ourselves and our families in regard to immunizations, but also where our governing entities, federally-funded, state-funded, and county-funded healthcare groups, organizations, and initiatives, all work hand in hand to offer free vaccination options, opportunities, and programs, for those of us who are interested in doing so. As a community, I truly feel we are all so very lucky and truly blessed!

82717 Wyoming Public
Vaccine Program Providers

Campbell County Public Health
ccgov.net
307.682.7275

Campbell County Memorial Hospital
ccgov.net
307.688.3272

Coalition Family Health Center
307.685.6500

Frontier Family Medicine, LLC
ffmwyoming.com
307.682.3333

Big Horn Pediatrics
307.687.1300

Content Sources

United States. Centers for Disease Control and Prevention. Flu Immunization: Reported Statistics, 2008-2012. By John Doe and Jane Smith. Atlanta, GA: CDC, 2013.

Influenza Activity, United States and Worldwide, September 5, 2015. MMWR September 18, 2015 / 64(36);1011-1016.

Flu vaccination in school kids helps protect everyone, By Shari Roan, Los Angeles Times, November 05, 2010.

Fluzone Quadrivalent vaccine [Prescribing Information]. Swiftwater, PA: Sanofi Pasteur Inc.

Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD).

 

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