Tag Archives: adjuvants

Example 1: Pediatric Practice is Opposite The Published Scientific Evidence On Early Vaccine Safety

The title sounds like a troll, but I will make it precise and document it with more than two dozen citations below, each linked. The precise statement will be falsifiable by a comment if I’m wrong.

The last few years I’ve come to realize that much of what I always implicitly thought true, is in fact a mirage, and come to understand much about why the world is the very different way it is, and something about how we might all better reach enlightenment.  I hope to explain this in some technical detail, and in return spark comments that enlighten me. I will begin with an example in the field of medical science, but examples in other fields will follow later, as well as discussion of why such crazy examples exist, and general first principle discussions in natural philosophy. By natural philosophy I mean the methods and rationality of physics applied to all, including philosophy and the affairs and inner workings of people.

I begin by posting the draft of a review article I intend to submit for publication in The Journal of Pediatrics, after a few days to let any readers out there post cogent comments or citations I should incorporate. If and when I get referee reports and the like back, I will post those too, even if they make me look stupid, as well as any responses I send back.

   The Published Data Shows Early Adjuvanted Vaccines are Dangerous

Abstract: We survey numerous publications on injections of  antigens or vaccine relevant quantities of aluminum salts into infant animal models, all of which report that they induce autoimmune disease or  brain damage if they occur during critical periods in development or are sufficiently repeated. We survey epidemiological studies bearing on the same issues, and find they support similar conclusions. We are unable to find cogent support in the peer-reviewed literature for the safety of injecting vaccines into infants. We make a few predictions about what other proposed epidemiological analyses would show. We remark on previous surveys that have failed to include any of the evidence surveyed here.

In 2002 the National Vaccine Program Office (NVPO) convened an expert group to study safety issues with adjuvants in vaccines. Among their conclusions:

pervasive uncertainty [from] missing data on pharmocokinetics and toxicities of aluminum injected into humans… There seems to be abundant data concerning risk levels for ingested aluminum, but scant data about risk levels for injected aluminum. The oral minimum risk level, for example, appears to be in the range of 2–60 mg/kg of aluminum per day but there are no comparable data for injected aluminum.”[1]

Doctors had been injecting aluminum adjuvants into children for 70 years, committees of doctors and government officials had decided numerous times to inject more aluminum into younger children, but as late as 2002 nobody had empirical data on toxicities of injected aluminum [1].

Since 2002 there has been extensive research. Infants get hundreds of times as much aluminum from vaccines as they do from breast milk [2, sec 4.2; 3]. Although some had suggested adjuvants would be safe because “most of the aluminum that enters the body is eliminated quickly” by the kidneys [4], this doesn’t apply to the particular salts of aluminum used in vaccines, particularly when they are bound up with antigens [2,sec 4.2]. Indeed this appears to be a design feature in making vaccines effective. Injections into infant animals of simple antigens, never mind antigen-aluminum combos, caused long-term brain damage when the injections occurred during critical periods in development, even when such injections would have been harmless at other times [2,sec 4.4; 5; 6]. A purpose of the adjuvant is to provoke a stronger response from infants’ immature immune systems than they would normally be capable of [7], indicating that, in fact, injecting adjuvanted vaccines may be more stressful than injecting the antigens that cause the brain damage in animal experiments [2 sec 4.4].  Immunizing mice 8 times with an antigen was reported to cause systemic autoimmunity [8], as did hyper-immunizing them for tetanus [9].  An H1n1 vaccine caused narcolepsy in some children by instigating an autoimmune attack on part of their brains [10].   An entire issue of Lupus [11,table of contents at http://lup.sagepub.com/content/21/2.toc ] was recently devoted to ‘ASIA’ – autoimmune/inflammatory syndrome induced by adjuvants [12], with at least 9 papers each presenting data indicating numerous autoimmune problems are caused by vaccine adjuvants.  Injections of aluminum into infant rats and mice in amounts comparable to what human infants receive resulted in brain inflammation and damage [13, 2 sec 4.5], and in an experiment where an analog of the aluminum content of the US vaccine series, and of the Swedish vaccine series, were injected into infant mice, the US series resulted in huge behavioral deficits (and 50% heavier adult mice) and the Swedish series resulted in lesser problems [14].

Also there have been epidemiological studies. Aluminum adjuvant levels are highly correlated with autism within countries across time and across countries [2], they are correlated across the 50 states with a 1% rise in vaccine compliance rate being associated with 680 extra cases of autism or language impairment (SLI)[15], Hep B shots (given early, with lots of aluminum) are highly correlated with autism [16] and with learning disability [17], the number of vaccines in a country’s schedule is highly correlated with infant mortality [18]. For each 7 vaccines added to a country’s schedule, there  is associated a rise in  the infant mortality rate of 1 per 1000, regressed over the 34 countries with lowest infant mortality rate. The US currently has 26 recommended vaccines before one year of age, and an IMR of 6.22 [18]. Some of the above studies are largely equivalent to the existence of a hidden factor (which might or might not be rising vaccines) causing rising autism at the same time as rising vaccines (strangely enough like the arguments most often given for vaccine effectiveness), but the ones adding in geographic dispersion each add in another independent degree of evidence.

I’ve so far found  only a handful of relevant papers that have been or might be seen as evidence for the other side, as discussed below. Every single published paper I’ve found in the scientific literature that reports empirical data on injections of aluminum or antigens into animal models, reports data that includes causing autoimmune disease or developmental brain damage. Every epidemiological study I’ve seen that reports data relevant to whether injecting  vaccines containing aluminum adjuvants into infants reports data suggesting its damaging, with a few exceptions that have been claimed one time or another to support safety. I will review these below.

DeStefano et al [20] has been cited as reporting: “The Risk of Autism Is Not Increased by ‘Too Many Vaccines Too Soon’”[21]. Unfortunately this paper, as indicated in its title, “Increasing Exposure to Antibody-Stimulating Proteins and Polysaccharides in Vaccines Is Not Associated with Risk of Autism”, compares patients who received more antigens rather than patients who receive more aluminum adjuvants. This compares one group of vaccinated patients to another, and there is no reason to believe either group had more aluminum, nor in fact much reason to believe they had more or earlier vaccines, nor does the paper make such a claim. So they wouldn’t find a connection even if adjuvant aluminum were the sole cause of autism.

According to table 1 in DeStefano, DTP has 3004 antigens, while no other vaccine except typhoid, which hardly appears in the data set, has a large number. So what their study effectively compares are high-antigen patients, those who got DTP, who score over 3004 antigens, and low antigen patients, who got other vaccines such as DTaP but did not get DTP, who score several dozen antigens if they got everything else but typhoid. Their claimed results indicate that DTP isn’t dramatically more likely to produce autism than DTaP, in patients who also got other vaccines. What’s particularly frustrating about this is it looks to me like if they just reanalyzed their data to weight by adjuvant content rather than antigens, replace table 1 with aluminum table and process, they would have a more pertinent result.

Every health comparison between vaccinated populations and unvaccinated populations I’ve seen, except as discussed below, the unvaccinated populations were much healthier. For example, here is a chart comparing chronic disease rates of a large German government survey of their vaccinated population to an unofficial, self-volunteered, survey of over 13,000 unvaccinated children.[22]


Something over 1/4 of the US population has at least one chronic disease, but much fewer unvaccinated people seem to. But perhaps these results are fully explained by hidden factors, maybe the unvaccinated are generally skeptical of doctors, and so get diagnosed less, or maybe only the healthy ones fill out surveys. This is always true of epidemiological studies as well. It’s hard to rule out hidden factors.

Two studies compared vaccinated to unvaccinated in developing nations, one in rural Guinea-Bissau in the 1990’s[23], and one in the Philippines in the early 1980’s[19] Note that in both these places the early vaccine schedule consists of BCG (or TB), DTP, and OPV, in the first months of life, and measles or MMR at 18 months. The only vaccine in this list with injected adjuvant is DTP.  These surveys found large unvaccinated populations, but the unvaccinated were clearly more deprived than the vaccinated– as shown by data like access to clean water and mothers’ education. So hidden factors appear to clearly favor the vaccinated.

In rural Guinea-Bisseau, scientists polled 15,351 mothers of 6 month olds to see which infants were vaccinated, and then came back a year later to see who was still alive. Kids who’d gotten at least one vaccine had a relative mortality of .74 compared to kids who’d gotten none. After cluster, age, and other vaccines were adjusted for, BCG was associated with mortality (0.55 (0.36 to 0.85)). However, recipients of at least one dose of DTP  had relative mortality (1.84 (1.10 to 3.10))  and recipients of one dose of OPV had relative mortality 1.81 (1.07 to 3.05). Recipients of measles vaccine had a mortality ratio of 0.48 (0.27 to 0.87). When deaths from measles were excluded from the analysis the mortality ratio was 0.51 (0.28 to 0.95).[23]

A second study in Guinea-Bisseau reports that having previously gotten DTP in addition to OPV more than doubled mortality for kids in the pediatric ward up to 5 years of age compared to kids who only got OPV, from 6% to 15%.[24]

These results suggest that DTP, and possibly OPV,  are doing harm. A hypothesis suggested by the above animal data on early injections, is that DTP is damaging the immune systems of the recipients so that they die of various causes. Moreover, BCG is a scratch, not an injection, and it’s effectiveness is controversial [25]. A hypothesis consistent with these facts is that BCG vaccine is serving largely as a placebo, doing neither harm nor good but merely a proxy for propensity to get vaccinated, a hidden factor representing parental circumstances and child raising skills. If that is the correct explanation, then the true increased mortality compared to a placebo for DTP in Guinea-Bisseau would be at least 3. Since measles deaths were not a factor,  and MMR is given at 18 months and does not contain adjuvants, MMR could have a similar role here.

In the Philippines, Bloom et al looked at scores on intelligence test results at about 12 years of age for a  population surveyed on vaccines at 24 months. They found a sample of only 85 children who had received all of DPT, measles, polio, and TB, and  a control sample of 1022 children who had received none of them, out of a total survey of 1975 children. Note the survivorship bias in the data. Any children who died before age 12  either from receiving the vaccines or from not receiving them, were not counted, and its unclear whether children who developed severe problems like autism would have been included either. They attempted to deal with the  hidden factor bias by choosing matched members of the unvaccinated for the vaccinated, based on fitting a simple linear regression to features like mother’s education and water supply in home. They then found that the fully vaccinated scored about half a standard deviation higher on cognitive tests and were about the same height and weight as the fully unvaccinated, although they note “the matching of treatment and control groups may be imperfect if there are unobserved confounding factors that affect both vaccination and cognitive development. We therefore do not see our results as definitive.”

A problem with this is there seems to be an evident confounding factor. It seems likely that virtually every parent in the Philippines, or at least virtually every intelligent, educated parent motivated to invest in their children, would have as an important goal vaccinating their children. If basic intelligence has any meaning, it is highly connected to ability to succeed at difficult real world tasks on which other, less intelligent people, might fail; and this task of getting children vaccinated further folds in motivation to invest in children. Thus succeeding in this task seems in and of itself as strong a proxy for propensity to produce smart children as one could think to devise. By choosing to consider only fully vaccinated children, Bloom et al have selected a group that is fully 1.5 to 2 standard deviations ahead of the mean at this proxy, the top 85 out of 1975 individuals in the distribution, and the controls are all in the lower half of the bell curve, so the  mean vaccinated are perhaps 2.5 standard deviations ahead of the mean control in this measure of propensity to produce smart children. That they are finding only .5 standard deviation increase in test scores and no benefit in height from this factor suggests the explanation that the vaccines are causing a 2 standard deviation loss compared to a placebo. I would suggest they reanalyze their data to deal with hidden factors as in the Guinea-Bisseau studies, by comparing individuals who got at least 1 DTP shot to individuals who got no vaccines, and that they compare individuals who got only BCG to individuals who got DTP. I predict if they do, they will find results like the Guinea-Bisseau studies showing that the early adjuvanted vaccination is causing damage.

Another study[26] compared outcomes in a largely unvaccinated population in Papua, New Guinea, reporting almost opposite results to the Guinea-Bisseau study, eg they found DTP greatly decreased mortality rates.  This study attempted to control for confounding factors using the method of propensity scores,  “an efficient estimator of the
adjustment estimand, formed by an arbitrary set of covariates S; it makes no statement
regarding the appropriateness of S, nor does it promise to correct for any confounding
bias, or to refrain from creating new bias where none exists.”[27,p 349] The set of covariates they corrected for did not contain the type of proxies for parental circumstances and abilities that the above two studies controlled for such as whether there is water or a toilet in the home, or maternal education or vaccine status. As with each of the above studies, it appears highly likely that parents with a high prior propensity to vaccinate their children also have a high propensity to feed them well and maintain sanitary circumstances. Furthermore, they binned by set of vaccines given, so that a patient who had only BCG would contribute person-days to the BCG bin until they died or got another vaccine, say DTP, in which case they began to contribute person days to the BCG+DTP bin. This method inherently biases the bins for fewer vaccines to be over-weighted with data for younger patients relative to bins for vaccine supersets, and since in their data the mortality rate for the youngest patients was far higher than for older ones, this injects a substantial bias into their reported results.

We found one other study[28] that is sometimes presented[29] as evidence for vaccine safety. Smith and Woods compared neuro-psychological results for patients who’d gotten all vaccines on time, compared to patients who hadn’t, and found no substantial differences. This study has essentially the same crucial confounder as the Philippines study in that demonstrated ability to give all the vaccines on time is a real world intelligence test and intuitively a strong proxy for prior propensity to produce smart children. In this case they roughly compared the upper half of their distribution to the lower half, so arguably started about a standard deviation ahead according to this prior propensity. Note also they are comparing one group of vaccinated children to another, who might even have gotten vaccines earlier in some cases, just not at the right times. Note also that some vaccines might have been postponed because the child was in some way unwell, or because the patient had had a bad reaction to prior vaccinations, the latter of which actually serves to bias the lower vaccine group to contain vaccine casualties if such exist.

Two other papers are sometimes suggested as defending vaccine aluminum[30,31]. Mitkus et al and Keith et al model the aluminum level in infants blood, and compare it to an MRL based on feeding post-weaning mice aluminum almost until they look visibly sick, and dividing the amount it took by 30. Both papers concur that infants receive hundreds as times as much aluminum in their blood from vaccines as from diet. Keith found that the aluminum levels would briefly spike over the MRL but for the most part remained below it. Mitkus changed some of the underlying assumptions and found that aluminum levels stayed below the MRL. Two points should be noted about these papers. First, neither reported any empirical data whatever. They are models. Second, the MRL’s are not informed in any way about the toxicity of injected aluminum in neonates.

We note in passing that reference [29], Vaccine Safety: Examine the Evidence by the American Academy of Pediatrics, does not mention any of the papers surveyed here that suggest risk, and thus appears more as an advocacy piece than concerned with fully informing patients. It surveys numerous papers suggesting MMR does not cause autism. There are also numerous papers suggesting it does. This issue is beyond the scope of this review, which is concerned with vaccines given in the first year of life, particularly those containing adjuvants, neither of which apply to MMR.

Likewise,  The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies from the Institute of Medicine of the National Academies [32], selected its papers for review in a manner that somehow missed every single paper cited herein, except for [28]. They provide some additional citations to epidemiological papers not reviewed here that suggest vaccines don’t cause auto-immune problems, presuming their results are not explained by confounding factors, but no additional citations that are reassuring on the subject of brain damage or aluminum adjuvants. All of their attention regarding brain damage was focused on thimerosal.

It is widely believed that medical interventions are allowed on the market only when they have been proved safe, and that Doctors take an oath to “First, do no harm.” Our survey has found that not only is there no proof of vaccine safety in the peer-reviewed literature, the overwhelming preponderance of the evidence suggests that early vaccines are causing damage. It’s past time for medical practice to take note.


[1] Vaccine 20 (2002) S1–S4 Conference report Workshop summary Aluminum in vaccines

[2] Tomljenovic L, Shaw CA. Do aluminum vaccine adjuvants contribute to the rising prevalence of autism? J Inorg Biochem. 2011 Nov;105(11):1489-99  http://omsj.org/reports/tomljenovic%202011.pdf

[3] Infants’ exposure to aluminum from vaccines and breast milk during the first 6 months,  Journal of Exposure Science and Environmental Epidemiology Volume 20, Issue 7, November 2010, Pages 598-601 Dórea JG, Marques RC  http://www.ncbi.nlm.nih.gov/pubmed/20010978

[4] http://www.chop.edu/export/download/pdfs/articles/vaccine-education-center/aluminum.pdf

Childrens Hospital of Pennsylvania, Vaccine Education Center, Q&A Volume 4 2012, Q&A Aluminum in Vaccines: What You Should Know

[5] M.A. Galic, K. Riazi, J.G. Heida, A. Mouihate, N.M. Fournier, S.J. Spencer, L.E. Kalynchuk, G.C. Teskey, Q.J. Pittman, The Journal of Neuroscience 28 (2008) Postnatal Inflammation Increases Seizure Susceptibility in Adult Rats


[6] Metabolic Brain Disease, Volume 26, Issue 3, September 2011, Pages 237-240, Peripheral immune challenge with viral mimic during early postnatal period robustly enhances anxiety-like behavior in young adult rats Konat, G. W.,  Lally, B. E. , Toth, A. A.,Salm, A. K.  http://www.ncbi.nlm.nih.gov/pubmed/21643765

[7] Vaccine. 2001 May 14;19(25-26):3331-46. Neonatal and early life vaccinology. Siegrist CA. http://www.ncbi.nlm.nih.gov/pubmed/11348697

[8] Self-Organized Criticality Theory of Autoimmunity, Ken Tsumiyama, Yumi Miyazaki,Shunichi Shiozawa,,December 31, 2009  http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008382

[9]Lupus.2012 Feb;21(2):195-202. doi: 10.1177/0961203311429816. Vaccine model of antiphospholipid syndrome induced by tetanus vaccine. Dimitrijević L, Živković I, Stojanović M, Petrušić V, Živančević-Simonović S. http://lup.sagepub.com/content/21/2/195.abstract

[10] Alberto K. De la Herrán-Arita, Birgitte Rahbek Kornum, Josh Mahlios, Wei Jiang3, Ling Lin1, Tieying Hou, Claudia Macaubas, Mali Einen, Giuseppe Plazzi, Catherine Crowe, Evan W. Newell, Mark M. Davis, Elizabeth D. Mellins, and Emmanuel Mignot.  CD4+ T Cell Autoimmunity to Hypocretin/Orexin and Cross-Reactivity to a 2009 H1N1 Influenza A Epitope in Narcolepsy. Sci Transl Med 18 December 2013, Vol. 5, Issue 216, p. 216


[11] Lupus February 2012 vol. 21 no. 2 table of contents at http://lup.sagepub.com/content/21/2.toc

[12] J Autoimmun. 2011 Feb;36(1):4-8. doi: 10.1016/j.jaut.2010.07.003. Epub 2010 Aug 13.‘ASIA’ – autoimmune/inflammatory syndrome induced by adjuvants. Shoenfeld Y, Agmon-Levin .  http://www.ncbi.nlm.nih.gov/pubmed/20708902

[13]X. Li,H. Zheng, Z. Zhang,M. Li, Z.Huang, H.J. Schluesener, Y. Li, S. Xu,Nanomedicine: Nanotechnology, Biology and Medicine 5 (2009) 473–479 Glia activation induced by peripheral administration of aluminum oxide nanoparticles in rat brains


[14] Administration of aluminum to neonatal mice in vaccine-relevant amounts is associated with adverse long term neurological outcomes  C.A. Shaw, Y. Li , L. Tomljenovic, Journal of Inorganic Biochemistry, V 128,  November 2013, Pages 237–244  http://www.sciencedirect.com/science/article/pii/S0162013413001773

[15] http://www.ncbi.nlm.nih.gov/pubmed/21623535 J Toxicol Environ Health A. 2011;74(14):903-16. A positive association found between autism prevalence and childhood vaccination uptake across the U.S. population. Delong G.

[16] Hepatitis B vaccination of male neonates and autism diagnosis, NHIS 1997–2002 CM Gallagher, MS Goodman – Journal of Toxicology and Environmental Health, Part A, 2010 http://www.ncbi.nlm.nih.gov/pubmed/21058170

[17]  Hepatitis B triple series vaccine and developmental disability in US children aged 1–9 years C Gallagher, M Goodman – Toxicological and Environmental Chemistry, 2008  http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCoQFjAA&url=http%3A%2F%2Fwww.researchgate.net%2Fpublication%2F228343791_Hepatitis_B_triple_series_vaccine_and_developmental_disability_in_US_children_aged_19_years%2Ffile%2F72e7e518267e93f58e.pdf&ei=SpcoU7vFEcrzoATBzIDoBA&usg=AFQjCNGluMuqSbNoBgQt9NE_-k1NzsXIBw&sig2=USctJH2a8GMvwnJaQann8Q&bvm=bv.62922401,d.cGU

[18] Hum Exp Toxicol. 2011 Sep;30(9):1420-8. doi: 10.1177/0960327111407644. Epub 2011 May 4. Infant mortality rates regressed against number of vaccine doses routinely given: is there a biochemical or synergistic toxicity? Miller NZ, Goldman GS. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3170075/

[19] David E. Bloom, David Canninga & Erica S. Shenoy, The effect of vaccination on children’s physical and cognitive development in the Philippines, Applied Economics
Volume 44, Issue 21, 2012 p 2777-2783


[20] “Increasing Exposure to Antibody-Stimulating Proteins and Polysaccharides in Vaccines Is Not Associated with Risk of Autism” by Frank DeStefano, Cristofer S. Price, and Eric S. Weintraub,  Journal of Pediatrics (www.jpeds.com), DOI 10.1016 2013.02.001


[21] http://www.jpeds.com/content/JPEDSDeStefano

Journal of Pediatrics editorial, March 29, 2013,  “The Risk of Autism Is Not Increased by ‘Too Many Vaccines Too Soon’”

[22] http://vaccineinjury.info/results-unvaccinated/results-illnesses.html

[23] http://www.bmj.com/content/321/7274/1435 Routine vaccinations and child survival: follow up study in Guinea-Bissau, West Africa Commentary: an unexpected finding that needs confirmation or rejection BMJ 2000; 321:1435 Ines Kristensen, Peter Aaby, Henrik Jensen.

[24] http://www.ncbi.nlm.nih.gov/pubmed/15297050 Vaccine. 2004 Aug 13;22(23-24):3014-7. Oral polio vaccination and low case fatality at the paediatric ward in Bissau, Guinea-Bissau. Aaby P, Rodrigues A, Biai S, Martins C, Veirum JE, Benn CS, Jensen

[25] P.E.M. Fine, Variation in protection by BCG: implications of and for heterologous immunity The Lancet, Volume 346, Issue 8986, P1339 – 1345, 18 November 1995

[26] Benefits of routine immunizations on childhood survival in Tari, Southern Highlands Province, Papua New Guinea, Deborah Lehmann,John Vail, Martin J Firth,  Nicholas H de Klerk and  Michael P Alpers, Int. J. Epidemiol. (2005) 34 (1): 138-148. doi: 10.1093/ije/dyh262


[27]Judea Pearl, “Understanding propensity scores“. Causality: Models, Reasoning, and Inference (Second ed.). New York: Cambridge University Press. ISBN 978-0-521-89560-6
[28] On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes, Michael J. Smith, Charles R. Woods, Pediatrics Vol. 125 No. 6 June 1, 2010 pp. 1134 -1141 (doi: 10.1542/peds.2009-2489)


[29] http://vaccinepapers.org/wp-content/uploads/AAP-Vaccines-studies.pdf

American Academy of Pediatrics, April 2013, Vaccine Safety: Examine the Evidence

[30] Mitkus RJ, King DB, Hess MA, Forshee RA, Walderhaug MO., Updated aluminum pharmacokinetics following infant exposures through diet and vaccination, Vaccine 29(51) 9538-43 2011. http://www.ncbi.nlm.nih.gov/pubmed/22001122

[31] Keith LS, Jones DE, Chou CH., Aluminum toxicokinetics regarding infant diet and vaccinations. Vaccine. 2002 May 31;20 Suppl 3:S13-7. http://www.ncbi.nlm.nih.gov/pubmed/12184359

[32] The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies (2013) Committee on the Assessment of Studies of Health Outcomes Related to the Recommended Childhood Immunization Schedule; Board on
Population Health and Public Health Practice; Institute of Medicine of the National Academies, http://www.iom.edu/Reports/2013/The-Childhood-Immunization-Schedule-and-Safety.aspx