Zohreh Karimi

Biology Of Toxins
4/13/2016
2nd Paper Interpretation

Seasonal Trivalent Inuenza Vaccination During Pregnancy and the Incidence of

Stillbirth: Population-Based Retrospective Cohort Study
Summary
The retrospective study used midwives' records for seasonal influenza vaccination and
stillbirth among 58,008 women who delivered during the 2012 and 2013 winter influenza
seasons in Western Australia. Stillbirth was defined as birth at 20 or more weeks'
gestation. Of 58,008 pregnant women, 377 had stillbirths (6.5 per 1000 births overall).
The 52,932 unvaccinated women had 5.0 stillbirths per 100,000 pregnancy days
compared with 3.0 for vaccinated women. Stillbirth was more common among women
with diabetes, women with hypertension, and women who smoked. Indigenous women
were about twice as likely to experience stillbirth, as were other women. After adjusting
for maternal smoking, indigenous status, and propensity for vaccination (accounting for
higher-risk pregnancies, in which women are more likely to be vaccinated), the
researchers found that stillbirth was 51% less likely among women who had been
vaccinated compared with those who had not been vaccinated. The largest relative
reduction in stillbirths corresponded to births immediately after peak influenza season.
As a result, mothers who received seasonal Trivalent Inuenza Vaccination (TIV) during
pregnancy were significantly less likely to experience stillbirth compared with
unvaccinated mothers.
In this study considering Stillbirths per 100,000 Pregnancy-days not per individuals
seems logical because mothers have different pregnancy durations. Pregnancy-days
indicated the period of times that individuals were vaccinated or unvaccinated during
pregnancy days regardless of the number of the mothers. However, the author should
classify mothers into two categories, high-risk mothers and low- risk mothers. Because
women who have stillbirths would almost always have fewer pregnancy days than
women who carry to term. Considering both high-risk and low-risk mothers together in a
group is a weird way of expressing stillbirth incidence. Lowe-risk mothers with full-term
pregnancy experience more days of pregnancy and increase the number of days in the
denominator of the stillbirth ratio, so the amount of the incidence will falsely decrease.
This error will increase by increasing the number of individuals in the groups
simultaneously.
Also, the author mentioned that postpartum surveys estimated that 25%36% of women
who were pregnant during the study period received seasonal TIV, but according to this
study 8.7% of the cohort received seasonal inuenza vaccine during their pregnancy. I
feel that reliance on providers to report vaccination and generalizability to pregnant
women in developing nations increased false negatives. However, the possibility of false
negatives in the control group is ignored by the researchers.

Zohreh Karimi
Biology Of Toxins
4/13/2016
2nd Paper Interpretation

Moreover, only factors that affect mothers are considered in the hazard ratio of stillbirth.
One of the main causes of stillbirth is fetus abnormality (existence of the mutated
genes) that is completely neglected by this paper. Researchers did not study the
mothers records to determine the history of disease that leads to stillbirth. None of the
stillbirths were excluded from the study. Remaining stillbirth cases that do not Influence
by environmental factors in the cohort study makes a false increase in stillbirth ratio that
affects the interpretation of the data. Ignoring this issue makes it harder to trust the
results.
Indeed, this study is observational and does not prove cause and effect, and that the
results may not be generalizable to other populations or other flu seasons. Scientific
research requires that studies be replicated and that the methodology is sound. Subtle
bias often contaminates research in a way that makes authors interpret results in a way
favorable to their hypotheses. This research also begs the question of what the
contribution is of unsuccessful immunization. It is well known that the flu vaccine has a
poor track record of producing positive and protective seri-responses. How this should
affect our interpretation of the data is far from clear.
In addition, a recent study has yielded more evidence that people who were vaccinated
three years in a row appeared to have a higher risk of being infected with the dominant
flu strain in the latter season. Although scientists can't explain the apparent negative
effects of serial vaccination. The findings raise questions about standard flu vaccination
recommendations, which stress getting a flu shot every year to fight off the evermutating viruses. This finding can lead to different outcomes in pregnant women who
received the vaccine in previous years of pregnancy in compared to those who were not
vaccinated before.
In general, if a link between flu season and stillbirth is found, it could have a major
impact on infant deaths and further research is warranted to better establish the links
between flu, seasonal flu vaccination, and stillbirth risk. It may be useful for
communicating the potential benets of seasonal inuenza vaccination to pregnant
mothers and their providers. Given the growing body of evidence supporting the health
benets to mother and infant, concerted efforts are needed to improve seasonal
inuenza vaccine coverage among pregnant women. Scientists should find the cause
and effect of flu vaccination on stillbirth by different experiments. Using animal trials to
assess these effects on other species might be worthwhile. There are different
parameters that may affect the interpretation of the study including various types of
influenza viruses and flu vaccines, and the different susceptibility of individuals between
and within races.