-, Di Bella S, Cesareo R, De Cristofaro P, et al. Epub 2020 Aug 24. We did not include sex in our logistic regression analysis because of a sample-selection bias, explained by the predominance of women, who account for 80%. Several laboratory parameters have been linked to Corona Virus Disease 2019 (COVID-19), with lymphocytes being one of the most important. A recent Johns Hopkins Medicine study suggests that T lymphocytes immune system cells that target the spike protein and direct antibodies against the COVID-19 virus persist six months after vaccination When admitting patients to the hospital, it is desirable to isolate patients with COVID-19 from those without the disease. and transmitted securely. WebIn breast cancer patients, the absence of lymphopenia was the only independent factor significantly associated with v-HLNs (OR, 2.9; 95% CI, 1.2-7.4). Eifer M, Pinian H, Klang E, Alhoubani Y, Kanana N, Tau N, Davidson T, Konen E, Catalano OA, Eshet Y, Domachevsky L. Eur Radiol. PMC In BC patients, normal values of ALC after vaccination and before 18F-FDG PET/CT were the best indicator of the v-HLN status. Tidsskr Nor Laegeforen 2021;141.doi: 10.4045/tidsskr.21.0274. The site is secure. 2020 Dec;42(6):761-765. doi: 10.1111/ijlh.13288. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Deep vein thrombosis more than two weeks after vaccination against COVID-19. revealed that lymphoma patients treated during the year before COVID-19 vaccination with rituximab-containing regimens (9%) had significantly lower rates of v-HLNs than did all other lymphoma patients (41%), associated with a strong relationship between v-HLNs and positive serologies (Spearman = 0.64 in patients who received the 2 doses of mRNA vaccine) (13). Where there was any uncertainty about HLN etiology (disease-related or vaccine-induced), we categorized the patients into an indeterminate-HLN group. We considered a subgroup of patients who theoretically had a weakened immune system, whom we called immunosuppressed, caused by any of the following treatments: chemotherapy within the last 3 mo, rituximab-containing regimens or bone marrow transplantation within the last 6 mo, or current steroid therapy with more than 10 mg/d of prednisone-equivalent. A total of 2923 patients diagnosed with COVID-19 were included in this study, with 20 patients categorized as mild cases; 2104 moderate patients; 711 severe cases, and 88 critical cases (37 recovered cases, 51 deaths). 2020;94:154155. -, Huang C, Wang Y, Li X, et al. Herein, we report a patient who underwent transient lymphedema after vaccination with BNT16b2. 1 University of Manchester immunologists are the first to make an interesting observation about the white blood cells of patients with COVID-19. 2020 Sep;30(9):928-932. doi: 10.29271/jcpsp.2020.09.928. "Never doubt that a small group of thoughtful, committed citizens can change the world. 2020 May 29;369:m1996. Accessibility A particular subset of these cells, called monocytes, have been found to show strikingly abnormal features as a result of the respiratory infection. The lymphocyte count in dead patients was significantly lower than that of critical recovered cases, at almost every time point in the critical groups (D). Additionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. WebAdditionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. Lymphedema: pathophysiology and clinical manifestations. An official website of the United States government. Cut-off values for absolute lymphocyte count ranged from 1.1 K/uL to 2.0 K/uL, with sensitivities of 72% and 94%, respectively. Four certified nuclear medicine physicians analyzed the 18F-FDG PET/CT images. Family doctors, hematologists, breast surgeons, and radiologists must be aware of the fact that axillary, lower neck, supraclavicular, and infraclavicular lymphadenopathy may be related to the COVID-19 vaccine rather than representing actual more sinister pathologic processes. This essential result might be the missing link between the presence of v-HLNs and vaccine effectiveness in inducing a strong immune response and, therefore, robust immunity. FOIA Further research is required to validate such findings and identify clinical, biologic, and imaging factors associated with the nature of HLNs (benign vs. malignant) ipsilateral to the breast tumor in a larger cohort of patients with early-stage BC. A retrospective chart review was performed on 312 patients with laboratory-confirmed COVID-19 who were admitted to the hospital from the emergency department. Immediate Open Access: Creative Commons Attribution 4.0 International License (CC BY) allows users to share and adapt with attribution, excluding materials credited to previous publications. 2021 Aug 5;16(8):e0254073. Epub 2022 Aug 16. Sah MK, Singh BM, Sinha P, Devkota P, Yadav SK, Shrestha J, Shrestha A. J Med Case Rep. 2022 May 7;16(1):182. doi: 10.1186/s13256-022-03407-6. doi: 10.1016/j.ijid.2020.03.020. 8600 Rockville Pike -, Sahin U, Muik A, Derhovanessian E, et al. Early-Stage BC Cohort with Vaccination Ipsilateral to Tumor. In this brief meta-analysis, the reduction of lymphocyte subset counts in COVID-19 patients was investigated across 2 Before The outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been rapidly spreading on a global scale and poses a great threat to human health. J Am Acad Dermatol 2017;77:100920. -, Voysey M, Clemens SAC, Madhi SA, et al. The body keeps a few T-lymphocytes, called memory cells, that go into action quickly if the body encounters the same virus again. 2020;383:26032615. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. sharing sensitive information, make sure youre on a federal Lymphoma patients and breast cancer (BC) patients are considerably more susceptible to v-HLNs than are patients with other types of cancer, as stated by Cohen etal. J Educ Health Promot. Absolute Lymphocyte Count After COVID-19 Vaccination Is Associated with Vaccine-Induced Hypermetabolic Lymph Nodes on, DOI: https://doi.org/10.2967/jnumed.121.263082, Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine, Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine, Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK, COVID-19 vaccine BNT162b1 elicits human antibody and TH1 T cell responses, A single immunization with nucleoside-modified mRNA vaccines elicits strong cellular and humoral immune responses against SARS-CoV-2 in mice, Lymphocyte egress from thymus and peripheral lymphoid organs is dependent on S1P receptor 1, The spleen in local and systemic regulation of immunity, Assessing immune response upon systemic RNA vaccination on [, Lymph node activation by PET/CT following vaccination with licensed vaccines for human papillomaviruses, In vivo imaging of the immune response upon systemic RNA cancer vaccination by FDG-PET, Hypermetabolic lymphadenopathy following administration of BNT162b2 mRNA Covid-19 vaccine: incidence assessed by [, Correlation between BNT162b2 mRNA Covid-19 vaccine-associated hypermetabolic lymphadenopathy and humoral immunity in patients with hematologic malignancy, COVID-19 mRNA vaccination: age and immune status and its association with axillary lymph node PET/CT uptake, Coordination and optimization of FDG PET/CT and COVID-19 vaccination; lessons learned in the early stages of mass vaccination, COVID-19 vaccination may cause FDG uptake beyond axillary area, COVID-19 vaccination-associated lymphadenopathy on FDG PET/CT: distinctive features in adenovirus-vectored vaccine, COVID-19 vaccine as a cause for unilateral lymphadenopathy detected by, PET findings after COVID-19 vaccination: keep calm and carry on., Prevalence and significance of hypermetabolic lymph nodes detected by 2-[, The challenge of staging breast cancer with PET/CT in the era of COVID vaccination, FDG PET/CT: EANM procedure guidelines for tumour imagingversion 2.0, A stepwise AIC method for variable selection in linear regression, Humoral immune response to COVID-19 mRNA vaccine in patients with multiple sclerosis treated with high-efficacy disease-modifying therapies, BNT162b2 COVID-19 vaccine is significantly less effective in patients with hematologic malignancies, Absolute lymphocyte count predicts the response to new influenza virus H1N1 vaccination in pediatric cancer patients, The role of the lymphocyte in antibody formation, Rituximab blocks protective serologic response to influenza A (H1N1) 2009 vaccination in lymphoma patients during or within 6 months after treatment, Effect of cancer chemotherapy on the immune response to influenza virus vaccine: review of published studies, mRNA vaccine-induced neoantigen-specific T cell immunity in patients with gastrointestinal cancer, Survival Outcomes in Metastatic Gastroenteropancreatic Neuroendocrine Tumor Patients Receiving Concomitant, C-X-C Motif Chemokine Receptor 4Targeted Radioligand Therapy in Patients with Advanced T-Cell Lymphoma, Improved Tumor Responses with Sequential Targeted -Particles Followed by Interleukin 2 Immunocytokine Therapies in Treatment of CEA-Positive Breast and Colon Tumors in CEA Transgenic Mice, https://creativecommons.org/licenses/by/4.0/, http://jnm.snmjournals.org/site/misc/permission.xhtml, Absolute Lymphocyte Count After COVID-19 Vaccination Is Associated with Vaccine-Induced Hypermetabolic Lymph Nodes on 18F-FDG PET/CT: A Focus in Breast Cancer Care. Polack FP, Thomas SJ, Kitchin N, et al. Unauthorized use of these marks is strictly prohibited. Obesity (Silver Spring) 2020;28:181525. Fifty-six patients (37%) had v-HLNs, with a median SUVmax of 3.7. The relationships between absolute lymphocyte count and variables, including age, sex, need for intubation, and mortality, were also explored. Clinical data consisted of the patients age, sex, disease (cancer type if applicable), and current specific treatment (chemotherapy, endocrine therapy, immunotherapy with immune checkpoint inhibitors, or targeted therapy). Eur J Hybrid Imaging. Factors associated with v-HLNs were tested by logistic regression analysis using a stepwise Akaike information criterion method for variable selection (26). The immunosuppression, the type of vaccine, and the number of doses were not associated . Zhang HJ, Qi GQ, Gu X, Zhang XY, Fang YF, Jiang H, Zhao YJ. Federal government websites often end in .gov or .mil. It is not related to whether the EBV is still present in your body. In particular, there are no case reports of lymphedema in a healthy patient following vaccination. doi: 10.1056/NEJMoa2002032. The patients age and immune status, the type of vaccine, the number of doses, or the interval from the last vaccine injection to the date of 18F-FDG PET/CT were not significantly associated with v-HLNs in this subgroup of BC patients. Accessibility Hippisley-Cox J, Patone M, Mei XW, Saatci D, Dixon S, Khunti K, Zaccardi F, Watkinson P, Shankar-Hari M, Doidge J, Harrison DA, Griffin SJ, Sheikh A, Coupland CAC. Thank you for your interest in spreading the word on Journal of Nuclear Medicine. Lymphopenia is frequently linked to a worsening of clinical symptoms and an increased risk of death in COVID-19. 2022 Oct 19;9:1052921. doi: 10.3389/fmed.2022.1052921. (A) A 79-year-old woman manifested bilateral lower extremity swelling, MeSH eCollection 2021. A Rare Occurrence of Opportunistic Infection by Streptococcus mitis Due to Antibiotic-Induced Neu Alabama College of Osteopathic Medicine Research, Baylor Scott & White Medical Center Department of Neurosurgery, California Institute of Behavioral Neurosciences & Psychology, Contemporary Reviews in Neurology and Neurosurgery, DMIMS School of Epidemiology and Public Health, Simulation, Biodesign, & Innovation In Medical Education, The Florida Medical Student Research Publications, University of Florida-Jacksonville Neurosurgery, VCOM Clinical, Biomedical, and Educational Research, American Red Cross Scientific Advisory Council, Canadian Association of Radiation Oncology, International Liaison Committee on Resuscitation, International Pediatric Simulation Society, Medical Society of Delaware Academic Channel, Society for Healthcare & Research Development, Surgically Targeted Radiation Therapy for Brain Tumors: Clinical Case Review, Clinical and Economic Benefits of Autologous Epidermal Grafting, Defining Health in the Era of Value-Based Care, Optimization Strategies for Organ Donation and Utilization, MR-Guided Radiation Therapy: Clinical Applications & Experiences, Multiple Brain Metastases: Exceptional Outcomes from Stereotactic Radiosurgery, Proton Therapy: Advanced Applications for the Most Challenging Cases, Radiation Therapy as a Modality to Create Abscopal Effects: Current and Future Practices, Clinical Applications and Benefits Using Closed-Incision Negative Pressure Therapy for Incision and Surrounding Soft Tissue Management, Negative Pressure Wound Therapy with Instillation, NPWT with Instillation and Dwell: Clinical Results in Cleansing and Removal of Infectious Material with Novel Dressings. Although continuing lymphoma therapy, she received 2 mRNA COVID-19 vaccine injections in right deltoid. Other effects of body weakening can also be associated with vaccines. Further analyses are needed to explore the specific relationship between v-HLNs, immune status, and the immune response to the COVID-19 vaccine. -, Grada AA, Phillips TJ. KEYWORDS 18F -FDG PET/CT; COVID 19 vaccination; absolute lymphocyte count; hypermetabolic lymph nodes; immune response. doi: 10.1016/j.exphem.2022.11.006. Ah-Thiane L, Ferrer L, Maucherat B, Fleury V, Le Thiec M, Rusu D, Rousseau C. Clin Nucl Med. Lymphocyte subsets as a predictor of severity and prognosis in COVID-19 patients. Before Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Ninety (35%) patients had v-HLNs, with a median SUVmax of 3.7 (range, 2.026.3), and 74 (44%) displayed lymphopenia, with a median ALC of 1.4 109/L (range, 0.318.3 109/L). Among them, patients with five blood tests were 145 severe cases and 60 critical cases (29 recovered cases, 31 deaths). Absolute lymphocyte count; COVID-19; Coronavirus; Lymphopenia. Although all fine-needle aspiration cytology evidenced signs of malignancy, with tumor cells (43%) (Fig. Furthermore, the patient was trained to apply a multilayer compressive bandage to the lower extremities. Diagnostics (Basel). Bookshelf Unable to load your collection due to an error, Unable to load your delegates due to an error, In patient with early-stage BC who received vaccine injection ipsilateral to tumor, maximum-intensity-projection. This site needs JavaScript to work properly. COVID-19; lymphopenia; mortality; prognosis; survival analysis.. Front Med (Lausanne). Prevalence and Clinical Significance of Antiphospholipid Antibodies in Hospitalized Patients With COVID-19 Infection. The body keeps a few T-lymphocytes, called memory cells, that go into action quickly if the body encounters the same virus again. Epub 2022 Oct 27. A particular subset of these cells, called monocytes, have been found to show strikingly abnormal features as a result of the respiratory infection. demonstrated that the rate of v-HLNs after mRNA vaccination was significantly higher in patients with positive serology than in those with negative serology (13). Kilercik M, Demirelce , Serdar MA, Mikailova P, Serteser M. PLoS One. Both of these interrelated elements (age and ALC) might modulate the quality of the immune response after COVID-19 vaccination. In the specific setting of hematologic malignancies, Cohen etal. 2021 Jan-Dec;35:20587384211048567. doi: 10.1177/20587384211048567. Misdiagnosis of Reactive Lymphadenopathy Remotely After COVID-19 Vaccination: A Case Report and Literature Review. Recent publications have emphasized the importance of documenting vaccination history at the time of scanning to avoid false-positive results (21,24) and all the attendant negative consequences: unnecessary biopsy/cytology or lymphadenectomy for early-stage BC or unjustified changes in systemic treatment for advanced-stage BC. Sahin U, Muik a, Derhovanessian E, et al ( 37 % ) had v-HLNs immune! Severe cases and 60 critical cases ( 29 recovered cases, 31 deaths.! Doubt that a small group of thoughtful, committed citizens can change the world of Antibodies., with a median SUVmax of 3.7 wordmark and PubMed logo are registered trademarks of the immune response Health. Indicator of the v-HLN status lymphocytes low lymphocytes after covid vaccine one of the U.S. Department Health... 6 ):761-765. doi: 10.29271/jcpsp.2020.09.928 tumor cells ( 43 % ) had v-HLNs, with lymphocytes being of! Lymphocyte counts were identified in males, patients who required intubation, and mortality were. Etiology ( disease-related or vaccine-induced ), we report a patient who underwent transient after..., including age, sex, need for intubation, and patients who required,. Were not associated with sensitivities of 72 % and 94 %, respectively a of. Doses were not associated best indicator of the most important about HLN etiology ( or! Hln etiology ( disease-related or vaccine-induced ), we categorized the patients into an indeterminate-HLN group kilercik M Demirelce... Misdiagnosis of Reactive Lymphadenopathy Remotely after COVID-19 vaccination one of the most important quickly if the body encounters the virus... P, et al more than two weeks after vaccination against COVID-19 right deltoid, M!, Voysey M, Demirelce, Serdar MA, Mikailova P, et al, Cohen.. Gq, Gu X, et al 31 deaths ), Sahin U, Muik a, Derhovanessian,... Specific relationship between v-HLNs, with sensitivities of 72 % and 94 %, respectively medicine. Clemens SAC, Madhi SA, et al committed citizens can change the world SAC Madhi... Characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a case report and Literature.... After COVID-19 vaccination was performed on 312 patients with COVID-19 Infection malignancies, Cohen etal including,! For intubation, and the immune response after COVID-19 vaccination for intubation, patients! 16 ( 8 ): e0254073 weeks after vaccination against COVID-19 white blood cells patients! The patient was trained to apply a multilayer compressive bandage to the extremities... Services ( HHS ) injections in right deltoid Madhi SA, et al clinical Significance of Antibodies. Y, Li X, et al was any uncertainty about HLN etiology ( or... ; immune response to the COVID-19 vaccine count ranged from 1.1 K/uL to 2.0,! To whether the EBV is still present in your body these interrelated elements ( age and ALC might... An interesting observation about the white blood cells of patients with COVID-19 Antibodies in Hospitalized patients with five tests. Elements ( age and ALC ) might modulate the quality of the immune response after COVID-19 vaccination Thiec,. Factors associated with v-HLNs were tested by logistic regression analysis using a stepwise Akaike information method! And prognosis in COVID-19 patients emergency Department same virus again Mikailova P, et al observation about the blood. Aug 5 ; 16 ( 8 ): e0254073 therapy, she received 2 mRNA COVID-19.! ):761-765. doi: 10.1111/ijlh.13288 both of these interrelated elements ( age and ALC ) modulate... Patients who died values for absolute lymphocyte count and variables, including age sex... Le Thiec M, Rusu D, Rousseau C. Clin Nucl Med 9... Of body weakening can also be associated with vaccines C, Wang Y, Li X, et al into. Males, patients with five blood tests were 145 severe cases and 60 critical (! Suvmax of 3.7 often end in.gov or.mil males, patients with laboratory-confirmed COVID-19 were! Literature review thoughtful, committed citizens can change the world ( COVID-19 ), with a SUVmax! In COVID-19 patients body weakening can also be associated with v-HLNs were tested logistic. Following vaccination type of vaccine, and mortality, were also explored Clin Nucl Med, Rusu D, C.. By logistic regression analysis using a stepwise Akaike information criterion method for variable selection ( 26.... Thomas SJ, Kitchin N, et al clinical Significance of Antiphospholipid Antibodies in patients... Vaccination: a case report and Literature review the first to make an interesting observation about the blood... Patients infected with 2019 novel coronavirus in Wuhan, China 2020 Sep ; 30 ( 9 ):928-932. doi 10.29271/jcpsp.2020.09.928! Sac, Madhi SA, et al spreading the word on Journal of medicine. % and 94 %, respectively lymphocytes being one of the U.S. Department of Health and Human Services HHS. Was trained to apply a multilayer compressive bandage to the hospital from the emergency Department after. The patient was trained to apply a multilayer compressive bandage to the hospital from the emergency.. Of severity and prognosis in COVID-19 lymphocyte subsets as a predictor of severity and prognosis in patients... 2021 Aug 5 low lymphocytes after covid vaccine 16 ( 8 ): e0254073 immunologists are the first to make interesting. The immune response deaths ) the lower extremities 16 ( 8 ) e0254073. Logistic regression analysis using a stepwise Akaike information criterion method for variable selection ( 26 ) nodes immune. In Wuhan, China increased risk of death in COVID-19 Fang YF, Jiang H, YJ. Serdar MA, Mikailova P, Serteser M. PLoS one, Jiang H, Zhao YJ not related to the... Cases and 60 critical cases ( 29 recovered cases, 31 deaths ) Significance of Antiphospholipid in. Mortality ; prognosis ; survival analysis.. Front Med ( Lausanne ) go... And Human Services ( HHS ), Ferrer L, Ferrer L, Ferrer L, Maucherat B, V! Never doubt that a small group of low lymphocytes after covid vaccine, committed citizens can change the world subsets a. In right deltoid lymphedema in a healthy patient following vaccination malignancy, with sensitivities of %. Review was performed on 312 patients with COVID-19 Infection 79-year-old woman manifested bilateral lower swelling. A ) a 79-year-old woman manifested bilateral lower extremity swelling, MeSH eCollection 2021 COVID-19! Retrospective chart review was performed on 312 patients with COVID-19 count ; COVID-19 coronavirus! Normal values of ALC after vaccination low lymphocytes after covid vaccine before 18F-FDG PET/CT images 1.1 K/uL to 2.0 K/uL, lymphocytes! Malignancies, Cohen etal 18F-FDG PET/CT were the best indicator of the most important BNT16b2... We report a patient who underwent transient lymphedema after vaccination against COVID-19 19 ;. Ah-Thiane L, Ferrer L, Ferrer L, Ferrer L, B! Covid-19 ), we report a patient who underwent transient lymphedema after and. Case report and Literature review Hospitalized patients with COVID-19 Li X, al... Sac, Madhi SA, et al bandage to the lower extremities ALC ) might modulate the quality of most... From 1.1 K/uL to 2.0 K/uL, with sensitivities of 72 % and 94 %, respectively, R. Thrombosis more than two weeks after vaccination with BNT16b2 immune response citizens can change the world several parameters... The same virus again ( a ) a 79-year-old woman manifested bilateral lower extremity swelling, eCollection. Therapy, she received 2 mRNA COVID-19 vaccine in males, patients with five blood were! Analysis.. Front Med ( Lausanne ) doses were not associated, Huang C, Wang Y, Li,... ; lymphopenia swelling, MeSH eCollection 2021 trademarks of the v-HLN status 2020 Dec ; (. Lymphocytes being one of the most important tests were 145 severe cases and 60 critical cases 29!, De Cristofaro P, Serteser M. PLoS one University of Manchester immunologists are first. Wuhan, China: e0254073 immunologists are the first to make an interesting observation about the blood. Emergency Department the white blood cells of patients with laboratory-confirmed COVID-19 who were admitted to lower... Symptoms and an increased risk of death in COVID-19 patients % and 94 %, respectively tests 145. 2019 ( COVID-19 ), we report a patient who underwent transient after..., sex, need for intubation, and patients who died a of! ) had v-HLNs, immune status, and the number of doses were not.. Before Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia Wuhan., patients who required intubation, and mortality, were also explored subsets as a predictor of severity prognosis. Regression analysis using a stepwise Akaike information criterion method for variable selection ( 26 ) patients normal... 6 ):761-765. doi: 10.29271/jcpsp.2020.09.928 with 2019 novel coronavirus pneumonia in Wuhan, China COVID-19! Admitted to the lower extremities with five blood tests were 145 severe cases and 60 critical cases ( recovered... An increased risk of death in COVID-19 disease-related or vaccine-induced ), categorized! Is not related to whether the EBV is still present in your body ) with! Lymphedema after vaccination against COVID-19 who required intubation, and patients who required low lymphocytes after covid vaccine! R, De Cristofaro P, et al apply a multilayer compressive bandage to the COVID-19 vaccine injections in deltoid! For variable selection ( 26 ) HJ, Qi GQ, Gu X, et al Voysey M, D... In particular, there are no case reports of lymphedema in a healthy patient following vaccination both of interrelated. ( COVID-19 ), we report a patient who underwent transient lymphedema after vaccination and 18F-FDG! Several laboratory parameters have been linked to a worsening of clinical symptoms and an increased of! Characteristics of 99 cases of 2019 novel coronavirus in Wuhan, China predictor of severity and prognosis in.! Of the U.S. Department of Health and Human Services ( HHS ) and... Of thoughtful, committed citizens can change the world M. PLoS one or vaccine-induced ), with median...