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independent assessment of the committee's conclusions, the committee wishes to make the process of its evaluation as explicit as possible.

The adverse events under consideration by the committee are, in most instances, rare in the exposed population. They also are known to occur in the absence of vaccination, are clinically ill-defined, and are generally of unknown causation in the general population. The exposures—pertussis and rubella vaccinations—are very widespread in the population, so that the absence of exposure may itself require an explanation in the interpretation of comparative studies. These and other features raise a number of difficulties both in the investigation and in the evaluation of the resulting evidence.

The committee considered causal questions of three kinds in connection with adverse events that have been reported to occur after administration of pertussis or rubella vaccine. The first of these questions about exposure to pertussis or rubella vaccine is, in general, can it cause the specified adverse condition? For example, can rubella vaccine cause chronic arthritis? If the conclusion is affirmative, a second question becomes pertinent: How frequently does it cause that condition? Or, how frequently is arthritis a result of rubella vaccination? The third question, which applies to a particular instance or case of an adverse event, is did it cause that specific event? Or, did rubella vaccine cause this particular individual to develop arthritis? The committee has undertaken its evaluation from a neutral posture, presuming neither the existence nor the absence of association between these vaccines and the events under consideration.

The identification and acquisition of the relevant evidence were major tasks of the committee throughout the course of its work. The preponderance of this material comprised either reports of controlled, observational epidemiologic studies (case-comparison or cohort studies) or uncontrolled case reports or case series. There was no experimental evidence, whether in humans or animals, that clearly proved or disproved a causal relation. Each study or report reviewed by the committee was first assessed individually and then, as appropriate, incorporated into the collective results that underlie the committee's conclusions.

Both quantitative and qualitative approaches to integration of the evidence were utilized. Formal meta-analysis was applied when it was feasible and appropriate. All of the studies were assessed insofar as possible with respect to the roles of error, bias, confounding, and chance in producing the observed results. Several considerations bearing on the inference that an association may reflect a true causal relation were also included in the committee's evaluation of the overall body of evidence pertaining to each type of adverse event under review. These included the strength of association, temporal relation between exposure and event, consistency of results between studies, specificity of the relation between exposure and event, and biologic plausibility of such a relation.



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