For them, it is an easy choice. They know that vaccines work, that vaccines are safe, and that vaccines are necessary.
Making the Right Choice About Vaccines
Some folks aren’t so sure though. They may either be against vaccines or might still be on the fence, not knowing for sure what to do.
“When my third child was born, I had more questions than answers and a huge reluctance to choose immunizations without certainty that the benefits outweigh the risks.”
Suzanne Walther on A Parent’s Decision on Immunization: Making the Right Choice
Mark Zuckerberg posted a photo when he took his daughter to their pediatrician for her vaccines.
Parents can be confident that all of the evidence points to the facts that:
Vaccines are effective at preventing disease. Vaccines work.
After they are approved, there are ongoing clinical trials and safety systems in place to rule out the possibility that vaccines could cause diseases later in life.
With all of the anti-vaccine information that is regularly posted on Facebook and anti-vaccine books listed on Amazon, it is no surprise that some parents would be scared though.
“I have discovered along the way that it is easy for parents to be misinformed. It is a real challenge to be well informed.”
Suzanne Walther on A Parent’s Decision on Immunization: Making the Right Choice
Believe it or not, some folks don’t think that coincidences are real.
Not believing in coincidences is a well known trope of the anti-vaccine movement.
Is it a coincidence that these folks are the ones who are the most likely to believe that vaccines cause a lot of injuries and vaccine induced diseases?
“When I undertook the study with the current vaccine strain on my own two triple-negative children and their three playmates, also triple- negatives, I thought: “I am going to do this very carefully now,” and, like Dr. Gear, I set up certain time schedules. I said: “I am going to start to give the vaccine now.” Every time I said “I am going to start to give it” and did not give it, two to three or four days later they came down with either pharyngitis, vomiting and abdominal pain, or a little fever.
I waited for approximately six weeks for those children to stop having some sort of febrile episode. I finally gave up. It so happened that after they got the vaccine they did not have any such episode.”
Albert Sabin on Recent Studies And Field Tests With A Live Attenuated Poliovirus Vaccine
When Albert Sabin was first researching his oral polio vaccine, he understood the problem. How could he really know if any signs or symptoms that occurred after he gave someone his vaccine were really caused by the vaccine, or just a coincidence?
“However, a report later to be given by Dr. Smorodintsev will deal with approximately 7,500 children who had received the vaccine and were carefully followed, as compared with another group, in similar number, who had not, for various types of illnesses which were occurring during the period.”
Albert Sabin on Recent Studies And Field Tests With A Live Attenuated Poliovirus Vaccine
The solution? They studied kids who had not gotten his vaccine.
You can just look at the background rate of a symptom or condition, and compare the periods before and after you start using a vaccine.
For instance, consider this study from Australia about using the HPV vaccine in boys, in which they made some predictions of what would happen after introducing the HPV vaccine.
Assuming an 80% vaccination rate with three doses per person — which equates to about 480 000 boys vaccinated and a total of 1 440 000 doses administered nationally per year in the first 2 years of the program — about 2.4 episodes of Guillain-Barré syndrome would be expected to occur within 6 weeks of vaccination. In addition, about 3.9 seizures and 6.5 acute allergy presentations would be expected to occur within 1 day of vaccination, including 0.3 episodes of anaphylaxis.
Clothier et al. on Human papillomavirus vaccine in boys: background rates of potential adverse events.
Wait. Are they saying that the HPV vaccine is going to cause Guillain-Barré syndrome, seizures, allergic reactions, and anaplylaxis?
Of course not. When the study was done, the kids hadn’t gotten any vaccines yet!
That was the background rate of those conditions.
They happened before the vaccine was given, and you can expect them to continue to happen after these kids start getting vaccinated – at that same rate.
What if they start happening more often after kids get vaccinated?
Then it makes it less likely to be a coincidence and more likely that the vaccine is actually causing an increase in the background rate. And vaccine safety studies look for that, which is how we know that vaccines don’t cause SIDS, transverse myelitis, multiple sclerosis, and many other conditions.
Most of you will have heard the maxim “correlation does not imply causation.” Just because two variables have a statistical relationship with each other does not mean that one is responsible for the other. For instance, ice cream sales and forest fires are correlated because both occur more often in the summer heat. But there is no causation; you don’t light a patch of the Montana brush on fire when you buy a pint of Haagan-Dazs.
Nate Silver on The Signal and the Noise
Of course, when we are talking about coincidences, we are also talking about correlation and causation.
When correlation doesn’t equal causation, then it’s probably a coincidence. Or it’s at least caused by some other factor.
And coincidences happen all of the time.
Is It a Vaccine Injury or a Coincidence?
That something could be a coincidence is not typically want parents want to hear though, especially if their child has gotten sick.
What does it mean that something happens coincidentally?
“Most sudden cardiac deaths that remain unexplained after necropsy are probably caused by primary cardiac arrhythmias.”
Sudden death in children and adolescents
Often it just means that it is unexplained. And that it is chance alone that it occurred as the same time as something else.
“In the absence of a specific etiology for ASDs, and a tendency among parents of children with a disability to feel a strong sense of guilt, it is not surprising that parents attempt to form their own explanations for the disorder in order to cope with the diagnosis.”
Mercer et al on Parental perspectives on the causes of an autism spectrum disorder in their children
Again, when folks blame vaccines, it is often because they have nothing else to blame.
“In some fraction of the American population, however, the belief in a link remains. One reason is a coincidence of timing: children are routinely vaccinated just as parents begin to observe signs of autism. Most vaccines are administered during the first years of life, which is also a period of rapid developmental changes. Many developmental conditions, including autism, don’t become apparent until a child misses a milestone or loses an early skill, a change that in some cases can’t help but be coincident with a recent vaccination.”
Emily Willingham on The Autism-Vaccine Myth
Think that it is too big of a coincidence that some infants develop spasms shortly after their four month vaccines?
Dr. William James West first described these types of infantile spasms in the 1840s!
And the “Fifth Day Fits,” seizures that began when a newborn was five days old, was described in the 1970s, well before we began giving newborns the hepatitis B vaccine.
But SIDS was only discovered after we began vaccinating kids, right?
“But, with millions upon millions of doses given each year to infants in the first 6 months of life across industrialized countries and with sudden infant death syndrome being the most common cause of infant death among infants 1 month or older, the coincidence of SIDS following DTP vaccination just by chance will be relatively frequent. When the two events occur, with SIDS following vaccination, well-meaning and intelligent people will blame the vaccine. They seek order out of randomly occurring events.”
Jacobson et al. on A taxonomy of reasoning flaws in the anti-vaccine movement
Of course not.
Cases of SIDS have been described throughout recorded history and have been well studied to prove that they are not associated with vaccines.
“Some events after immunisation are clearly caused by the vaccine (for example, a sore arm at the injection site). However, others may happen by coincidence around the time of vaccination. It can therefore be difficult to separate those which are clearly caused by a vaccine and those that were going to happen anyway… Scientific method is then used to determine if these events are a coincidence or a result of the vaccine.
Vaccine side effects and adverse reactions
It is easy to blame a vaccine when something happens and a child was recently vaccinated. That is especially true now that anti-vaccine folks turn every story of a child’s death or disability into a vaccine injury story.
“Autism was known well before MMR vaccine became available.”
Chen et al. on Vaccine adverse events: causal or coincidental?
Blaming vaccines when it is clear that vaccines aren’t the cause doesn’t help anyone though. It scares other parents away from vaccinating and protecting their kids. And it doesn’t help parents who need support caring for a sick child or help coping with the loss of a child.
What to Know About Vaccine Injuries vs Coincidences
While all possible adverse events after getting a vaccine should be reported to VAERS and your pediatrician, remember that just because something happened after getting vaccinated, it doesn’t mean that it was caused by the vaccine.
It sounds like a lot because it is an inflated number that is meant to scare parents.
Kids today do routinely get:
13 vaccines, including 5 doses of DTaP, 4 doses of IPV (polio), 3 or 4 doses of hepatitis B, 3 or 4 doses of Hib (the number of doses depends on the vaccine brand used), 4 doses of Prevnar, 2 or 3 doses of rotavirus (the number of doses depends on the vaccine brand used), 2 doses of MMR, 2 doses of Varivax (chicken pox), 2 doses of hepatitis A, 1 doses of Tdap, 2 or 3 doses of HPV (the number of doses depends on the age you start the vaccine series), 2 doses of MCV4 (meningococcal vaccine), and yearly influenza vaccines
protection against 16 vaccine-preventable diseases, including diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, chicken pox, pneumococcal disease, hepatitis A, hepatitis B, meningococcal disease, HPV, rotavirus, Hib, and flu
about 28 doses of those vaccines by age two years (with yearly flu shots)
about 35 doses of those vaccines by age five years (with yearly flu shots)
as few as 23 individual shots by age five years if your child is getting combination vaccines, like Pediarix or Pentacel and Kinrix or Quadracel and Proquad
about 54 doses of those vaccines by age 18 years, with a third of that coming from yearly flu vaccines
How do you get a number like 72?
You can boost your count to make it look scarier by counting the DTaP, MMR, and Tdap vaccines as three separate vaccines each, even though they aren’t available as individual vaccines anymore.
To boost the Vaccine Doses for Children a bit more, they add pregnancy doses too.
This trick of anti-vaccine math quickly turns these 8 shots into “24 doses.”
It’s not a coincidence.
Anti-vaccine folks want to scare you into thinking that vaccines are full of toxins, that kids get too many vaccines, that we give many more vaccines than other countries, and that this is causing our kids to get sick.
Can an unvaccinated child really get tetanus after a toe nail injury? Photo by Petrus Rudolf de Jong (CC BY 3.0)
None of it is true.
At age four years, when your preschooler routinely gets their DTaP, IPV, MMR, and chicken pox shots before starting kindergarten, how many vaccines or doses do you think they got? Two, because they got Kinrix or Quadracel (DTaP/IPV combo) and Proquad (MMR/chickenpox combo)? Four, because they got separate shots? Or Eight, because you think you should count each component of each vaccine separately?
Know that even if you do want to count them separately, it really just means that with those two or four shots, your child got protection against eight different vaccine-preventable diseases – diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, and chicken pox.
Vaccine-preventable diseases that have not disappeared, something that the “72 doses” sites don’t ever warn you about.
What to Know About Anti-Vaccine Math
Many websites use anti-vaccine math to inflate vaccine dose numbers and scare parents away from vaccinating and protecting their kids.
It is bad enough that folks in the anti-vaccine movement use propaganda to scare parents away from vaccinating and protecting their kids.
“The anti-vaccine argument is wrong in both the scientific and moral sense.”
Sarah Kurchak on Here’s How the Anti-Vaccination Movement Hurts Autistic People
Many people also think that the anti-vaccine message is anti-autism.
How the Anti-Vaccine Movement Takes Advantage of Dead Children and Their Parents
But just when you thought that they couldn’t go any lower, folks in the anti-vaccine movement find new ways to demonstrate their lacks of morals.
As a physician, I assure you this story isn’t believable at any level. In my opinion, the “health officials” are conjuring meningitis fairy tales about an “unvaccinated” boogeyman to cover for the much more probable cause of this child’s death: VACCINES.
The much more likely cause is right in front of us: “The child had just received his 4-month-old vaccinations two days beforehand.”
“Notice that THREE of the vaccines given at 4 months are for organisms capable of invading the brain and causing MENINGITIS. Rotavirus is a live virus vaccine capable of shedding from recently vaccinated children. The vaccine pre-clinical trials lacked placebo controls and were associated with infant deaths.
It doesn’t take my medical degree to understand how flimsy are the claims in this story.”
Jim Meehan
While rotavirus is a live virus vaccine, rotavirus rarely causes central nervous system disease. And he died of bacterial meningitis. It shouldn’t take a medical degree to know that rotavirus is a virus, not a bacteria.
While two of the other vaccines routinely given at four months do actually protect you from meningitis, both Prevnar and Hib are sub-unit vaccines, so can’t actually cause disease. Unfortunately, at four months, he would have been only partially protected against Prevnar and Hib, having only received two of four dosages of those vaccines.
“They expect the general public to be ignorant of the fact that we can actually measure the presence of the meningitis causing organisms for which there are vaccines: Haemophilus influenzae, Pneumococcus, and Meningococcus. So, where are the tests that confirm the presence of one of these “vaccine preventable” organisms?! Where’s the spinal tap/CSF pathology report?
As hard as it is for a grieving family to conceive of an autopsy, I pray the family demands a confirmation of the farcical cause of death being contrived in this case.”
Jim Meehan
Has Jim Meehan heard of HIPAA?
Does he read any of the other messages when he is writing his own comments about this family?
Why should this family have to come out and give an explanation for how their child died?
Is Jim Meehan really a doctor? It shouldn’t take a medical degree to understand that carriers of a disease don’t usually have symptoms of the disease.
“Again, from the article: “Health care officials told Dempsey they BELIEVE an unvaccinated person was carrying meningitis and Killy happened to come into contact with that person.”
They “believe”…give me a break. It should have said, “they made-up a story to cover for the real cause.”
SECOND, people don’t walk around with meningitis. They lay in their beds in a dark room and writhe in pain.
THIRD, the likelihood that an unvaccinated individual was walking around with meningitis is vanishingly small. To even list that in the top 100 options of a differential diagnosis is pure fiction.
FOURTH, where is this hypothetical unvaccinated meningitis shedding “patient zero?” He or she would have been so obviously sick that there is no way new parents would not remember the likely suspect…unless the suspect never existed.”
Jim Meehan
In this case, with a meningococcal infection, which is what the infant is thought to have, about 10% of people are carriers, asymptomatically having the Neisseria meningitidis bacteria in their nose or throat.
In the United States, we have two types of meningococcal vaccines, neither of which is routinely given to infants:
Menactra and Menveo – meningococcal conjugate vaccines that protect against serogroups A, C, W, Y and first given when kids are 11 to 12 years old, with a booster at age 16 years.
Bexsero and Trumenba – meningococcal conjugate vaccines that only protect against serogroup B and can be given to kids at increased risk and teens and young adults who want to reduce their risk of getting MenB disease
The only other possibility, since they mentioned that exposed people received antibiotics, would be the Hib bacteria.
“In the prevaccine era, Hib could be isolated from the nasopharynx of 0.5%–3% of normal infants and children but was not common in adults.”
CDC on the Epidemiology and Prevention of Vaccine-Preventable Diseases
Again, these carriers can be contagious, even though they don’t have any symptoms.
“It’s likely that these “health officials” are covering for the pharmaceutical/vaccine industry that pays them so well. It’s “health officials” like this that for decades have pretended that sudden unexplained infant death syndrome (SUIDS), not only has no explanation, but it couldn’t possibly be related to the injection of neurotoxic doses of aluminum into the bodies of tiny baby humans. They can ignore the clustering of infant deaths that occurs around the same times that CDC recommends multiple (5-13) vaccines at one visit, but I won’t.”
Jim Meehan
Why is a family that just lost their child getting harassed by anti-vaccine folks?
This is the modern anti-vaccine movement.
One clue is that Jim Meehan is pushing the idea that there is a Big Pharma conspiracy behind this child’s death.
An anti-vaccine parenting group helping spread misinformation about this baby’s death.
And there are many anti-vaccine parenting groups that are helping spread his message around.
Of course, this isn’t the first time this has happened.
Anti-vaccine folks routinely hound parents who die of SIDS and shaken baby syndrome, working to convince them that vaccines caused their deaths.
Even infants who die of vitamin K deficiency bleeding because they skipped their baby’s vitamin K shot all of a sudden have a vaccine injury.
They turn every story of a child’s death or disability into a vaccine injury story.
Everyone knows that the DPT vaccine caused a lot of vaccine injuries, right?
“I got interested in the topic of vaccines way back in medical school. A friend of mine convinced me to read a book about vaccines, and it ended up being a very anti-vaccine book. It was all about an old vaccine called the DTP vaccine that we don’t use anymore. But the book talked a lot about the risks and the dangers of that vaccine. The author of that book was calling for that vaccine to no longer be used.
A number of years later, it turns out that they did discover that vaccine was causing a lot of very severe, life-threatening, even fatal side effects, so they did end up taking that vaccine off the market.
So it kind of opened my eyes to the fact that there are some very severe, fortunately very rare, side effects to vaccines, and I wanted to learn more about this issue. I started reading a lot more books.”
Bob Sears, MD on The Vaccine War
After all, it was after reports of those vaccine injuries, including seizures and encephalitis, that led to:
Barbara Loe Fisher, believing that her child was damaged by the DPT vaccine, forming the Dissatisfied Parents Together organization (she later changed the name to the National Vaccine Information Center), and writing the book DPT: A Shot in the Dark (this is the anti-vaccine book that Bob Sears is talking about above)
the National Vaccine Injury Compensation Act passing in 1986, creating the National Vaccine Injury Compensation Program and the Vaccine Court
the DTaP vaccine replacing the DTP vaccine
But were those reports true?
And did they ever really discover that the DPT “vaccine was causing a lot of very severe, life-threatening, even fatal side effects,” which led to them “taking that vaccine off the market” as Dr. Bob said?
“During the period of transition from use of whole-cell DTP to DTaP, whole-cell DTP is an acceptable alternative to DTaP for any of the five doses. For the first four doses, whole-cell DTP combined with Hib vaccine (DTP-Hib vaccine) is an acceptable alternative to DTaP and Hib vaccine administered at separate sites.”
ACIP on Pertussis Vaccination: Use of Acellular Pertussis Vaccines Among Infants and Young Children Recommendations of the Advisory Committee on Immunization Practices
No, it was replaced by a newer vaccine – DTaP.
And actually, it is still used in some parts of the world.
The whole-cell DTP vaccine did cause more side effects than the newer DTaP vaccine, but we are talking about relatively mild side effects, like local reactions, pain, and fever. And while that it is good, it comes at a cost, a less effective vaccine.
What about epilepsy and encephalitis?
After all of the scare about the DPT vaccine, studies quickly showed that it didn’t cause all of the bad side effects that folks say it did.
One clue that the DTP vaccine didn’t cause many of the problems that were blamed on it, is that the same vaccine lawsuits that were succeeding in driving vaccine manufacturers out of business in the United States, were failing in the UK.
“Where given effects, such as serious neurological disease or permanent brain damage, occur with or without pertussis vaccination, it is only possible to assess whether the vaccine is a cause, or more precisely a risk factor, when the background incidence of the disease is taken into account. The question therefore is, does the effect occur more often after pertussis vaccination than could be expected by chance?”
Justice Jeremy Stuart-Smith
There is also the fact that many children who were originally thought to have been vaccine injured after their DPT vaccine are now known to have Dravet syndrome.
Without a diagnosis, Cossolotto said, she would probably still believe — erroneously — that the DPT shot caused Michaela’s illness. “I understand this is a genetic condition,” she said. “Having an answer does make a difference.”
Medical mystery: Seizures strike baby after routine vaccine
And then there are the reports and studies that found:
no association with brain injury, epilepsy, SIDS, or infantile spasms
no increased risk for serious neurological illness in the week after getting vaccinated with DPT
no increased risk for encephalopathy in the 90 days after receiving DTP and MMR vaccines
no difference in severe reactions after DPT vs DTaP, including encephalopathy, seizures, and allergic reactions
So no, the DPT vaccine was never really as dangerous as folks said or thought it was, despite what you might read or hear in anti-vaccine books or news reports.
What to Know About the Safety of the DPT Vaccine
Misconceptions about the risks and safety of the DPT vaccine created the modern anti-vaccine movement and unfortunately, continues to influence many people.
Of all of the myths about vaccines that confuse and scare some parents, those about infant mortality rates can be especially hard to easily put aside.
After all, why doesn’t the United States rank better for infant mortality rates since most parents do vaccinate and protect their kids?
Vaccines and Infant Mortality Rates
That’s actually fairly easy to answer.
“Globally, the infant mortality rate has decreased from an estimated rate of 64.8 deaths per 1000 live births in 1990 to 30.5 deaths per 1000 live births in 2016.”
WHO on Infant Mortality Situation and Trends
Vaccine-preventable diseases don’t have much effect on infant mortality rates in the United States these days.
In fact, infant mortality rates continue to drop and are now at their lowest levels ever.
While it is good news that the rate is dropping, most folks think they can be better.
For one thing, some states, like Mississippi, Louisiana, Alabama, Arkansas, and West Virginia, etc., have much higher infant mortality rates than others. Why? Much of those differences, can be explained by socio-economic factors. That’s also though to explain much of the differences in infant mortality rates between the U.S. and other developed countries, most of which have universal health care.
New Jersey, although they have ranked high for autism rates, has lower than average rates of infant mortality.
Another big difference is that many countries count infant mortality rates using different criteria than the United States.
For example, it is estimated that at least 40% of the differences between infant mortality rates in the United States and other countries is due to those countries not counting extremely preterm births among their statistics.
But why has the United States’ infant mortality ranking fallen relative to other developed nations?
OECD data shows that most European Countries have historically had much higher infant mortality rates than the US, which have affected relative rankings, even as all countries have seen infant mortality rates fall.
Although anti-vaccine groups try to tie this to ‘routine vaccination,’ it is easy to see that other countries have historically had much higher infant mortality rates than the United States. As they have caught up, the United States’ ranking has dropped relative to theirs, even though all have seen infant mortality rates drop.
Infant Mortality Rates in the Pre-Vaccine Era
But if you really want to understand the relationship of vaccines to infant mortality rates, you just have to look back to the pre-vaccine era. Back then, now vaccine-preventable diseases did have a big effect on infant mortality rates in the United States and elsewhere.
In 1910, for example, the most common causes of death for infants under 1 year were:
diarrhea and enteritis
premature birth
congenital debility
bronchopneumonia
pneumonia
malformations
bronchitis
convulsions
injuries at birth
whooping cough
tuberculosis
meningitis
measles
accident
diphtheria
Although advances in modern medicine would help decrease the mortality from many of those diseases, it was vaccines that truly worked to make sure they were no longer a big part of our infant mortality statistics.
How will we continue to decrease our infant mortality rates?
Most experts think that it will require better access to health care for all members of society.
What to Know About Infant Mortality Rate Rankings
Infant mortality rates are not linked to vaccines.
In the 1970s, many folks tried to say that the DPT caused SIDS. It didn’t.
Rates of most causes of sudden infant death, including SIDS, have dropped since the mid-1990s.
Fortunately, because SIDS rates have dropped so much over the years, even as we have added vaccines to the immunization schedule that protect infants against more diseases, it is easy for most parents to see that vaccines are not associated with SIDS.
Well, that isn’t exactly true. Getting vaccinated is actually thought to have a protective against SIDS…
Was SIDS Discovered Only After We Began Vaccinating Kids?
What about the idea that infants only started dying of SIDS after more kids started getting vaccinated?
Any truth to that?
Well, let’s start with when the term SIDS was first used, in 1969, when it was mentioned at the Proceedings of the Second International Conference on Causes of Sudden Death in Infants.
So would that make 1960 the year for “the initiation of routine vaccination?”
That would be a surprise to the kids in the 1940s who were already getting DPT, smallpox, tetanus, and typhoid vaccines.
“Sudden unexpected death in infancy, or “crib death,” is probably not a new syndrome, but it is one that has been clearly delineated and brought into sharp focus during the past 10 years. The first international conference on this subject, held in 1963, did much to formulate the salient features and to suggest the major areas open to research.”
Bergman et al on Sudden Infant Death Syndrome: Proceedings of the Second International Conference on Causes of Sudden Death in Infants
So just because SIDS finally got a name and an ICD9 code in 1969, that doesn’t mean that is when it first appeared.
Dr. Kemkes investigated whether 19th century infant deaths attributed to smothering or overlaying shared the same characteristics as known SIDS cases. She analyzed data from the U.S. Federal Mortality Schedule from the years 1850-1880. She found that, just like SIDS, smothering and overlaying deaths occurred primarily during the second to fourth month of the baby’s life, were more likely in the late winter months and amongst boys, and there were more infant deaths among black babies.
The author concludes: “The study strongly supports the hypothesis that these infant deaths represent empirical evidence of 19th century SIDS mortality.”
Was SIDS the cause of infant deaths even 150 years ago?
To get ahead of anti-vaccine folks, while the smallpox vaccine came out in 1798, a similar case can be made for accidental smothering deaths in the medieval period and Renaissance – and before.
Infants have likely been dying of SIDS for ages – it just wasn’t called SIDS and was blamed on other things.
“During the night this woman’s son died because she lay on him.”
1 Kings 3:19
In fact, many people even think that “SIDS” is mentioned in the Bible and was described by the ancient Egyptians and early Greeks.
And again, if vaccines somehow cause SIDS, why have rates of SIDS dropped so much as more and more kids get vaccinated and protected?
What to Know About the History of Vaccines and SIDS
The establishment of SIDS as a medical term in 1969 has nothing to do with vaccines or the immunization schedule.
