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Influenza vaccines include live attenuated and inactivated forms. Inactivated vaccines contain three or four different viral strains selected by the World Health Organization to cover influenza A H1N1 and H3N2, as well as influenza B, and are usually administered by intramuscular injection. The live attenuated influenza vaccine contains a cold-adapted strain and is given as a nasal spray. Most influenza vaccine strains are cultivated in fertilised chicken eggs (pictured), a technique developed in the 1950s; others are grown in cell cultures, and some vaccines contain recombinant proteins. Annual vaccination is recommended for high-risk groups and, in some countries, for all those over six months. As the influenza virus changes rapidly by antigenic drift, new versions of the vaccine are developed twice a year, which differ in effectiveness depending on how well they match the circulating strains. Despite considerable research effort for decades, no effective universal influenza vaccine has been identified. A 2018 meta-analysis found that vaccination in healthy adults decreased confirmed cases of influenza from about 2.4% to 1.1%. However, the effectiveness is uncertain in those over 65 years old, one of the groups at highest risk of serious complications.