Authors’ reply: Safety of Human Papillomavirus Vaccines
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We strongly disagree with the assertions made by Chandler et al.  and Martinez-Lavin  regarding our use of evidence  and with the validity of the alternative information presented by the authors.
Chandler et al.  contend that a hierarchy of evidence is outdated and that we use epidemiological evidence to “trump” the findings of case reports and case series. The evidence hierarchy used to structure our review is a globally accepted paradigm in modern clinical medicine and healthcare . Modifications to this hierarchy routinely place case series and case reports as the lowest level of evidence , reflecting their high risk of bias. We note that both Chandler et al.  and Martinez-Lavin  cite multiple very small and largely observational studies with no controls, several of which have been criticized [6, 7]. This is despite Martinez-Lavin  questioning the validity of “small” clinical trials.
The vast majority of evidence-based reviews on any topic do not include...
Compliance with Ethical Standards
No sources of funding were used to assist in the preparation of this study.
Conflicts of interest
Kristine Macartney, Anastasia Phillips, Alexis Pillsbury and Cyra Patel have no conflicts of interest that are directly relevant to the content of this study. Julia Brotherton is employed as the Director of the National HPV Vaccination Program Register, which is owned and funded by the Australian Government Department of Health. She has been an investigator on investigator-initiated HPV epidemiology studies that have received unrestricted partial funding for laboratory components from Seqirus (cervical cancer typing study) and Merck (recurrent respiratory papillomatosis study) but has never received any personal financial benefits.
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