Lancet. 8/08: Flu vaccination not associated with reduced risk of pneumonia

[Hannah Bell]

Aug 2;372(9636):398-405.

Influenza vaccination and risk of community-acquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study.Jackson ML, Nelson JC, Weiss NS, Neuzil KM, Barlow W, Jackson LA.

Group Health Center for Health Studies, Seattle, WA 98101-1448, USA. [e-mail]

BACKGROUND: Pneumonia is a common complication of influenza infection in elderly individuals and could therefore potentially be prevented by influenza vaccination. In studies with data from administrative sources, vaccinated elderly people had a reduced risk of admission for pneumonia compared with unvaccinated seniors; however, these findings could have been biased by underlying differences in health between the groups. Furthermore, since most individuals with pneumonia are not treated in hospital, such studies should include both outpatient and inpatient events. We therefore assessed whether influenza vaccination is associated with a reduced risk of community-acquired pneumonia in immunocompetent elderly people after controlling for health status indicators.

METHODS: We did a population-based, nested case-control study in immunocompetent elderly people aged 65-94 years (cases and controls) enrolled in Group Health (a health maintenance organisation) during the 2000, 2001, and 2002 preinfluenza periods and influenza seasons. Cases were individuals with an episode of outpatient or inpatient community-acquired pneumonia (validated by review of medical records or chest radiograph reports). We randomly selected two age-matched and sex-matched controls for each case. The exposure of interest was influenza vaccination. We reviewed medical records to define potential confounders, including smoking history, presence and severity of lung and heart disease, and frailty indicators.

FINDINGS: 1173 cases and 2346 controls were included in the study. After we adjusted for the presence and severity of comorbidities, as defined by chart review, influenza vaccination was not associated with a reduced risk of community-acquired pneumonia (odds ratio 0.92, 95% CI 0.77-1.10) during the influenza season.

INTERPRETATION: The effect of influenza vaccination on the risk of pneumonia in elderly people during influenza seasons might be less than previously estimated.

FUNDING: Group Health Center for Health Studies internal funds and Group Health Community Foundation fellowship grant.


http://www.ncbi.nlm.nih.gov/pubmed/18675690?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

[WildClarySage]

1. Imagine that... the flu vax doesn't protect people from pneumonia.

Next you'll be telling us that socks don't protect people from getting their feet wet. :eyes:

[Orrex]

2. Oh shit! I think that my socks contain Thimerosal!

Now I've got something else to worry about. Thanks a bunch.

[HamdenRice]

5. You do realize that this post makes you seem scientifically ill informed, right?

One possible severe consequence of influenza is pneumonia. That's one of the ways that influenze can become fatal. If there is no statistical link between influenza vaccination and reduced rates of pneumonia, then one of the main raisons d'etre for influenza vaccination turns out to be invalid.

Your post seems to falsely implying that there is no etiological correlation between influenza and pneumonia.

[Orrex]

6. Well, help me out here

Is the study saying "people who contract influenza and have received the vaccine are equally at risk for pneumonia as people who contract influenza but have not received the vaccine? That's how I'm reading it, and it makes perfect sense; the vaccine is not intended as direct protection against pneumonia, so there should be no expectation that it provides such protection, just as wearing socks isn't intended to keep one's feet dry.

I read it as stating the following: if an elderly person contracts influenza, he or she is more or less equally at risk of developing pneumonia regardless of whether or not he or she has received the flu vaccine.

Do you have a different interpretation? I admit that I may be misreading it.

[HamdenRice]

9. You seem not to understand the relationship between influenza and pneumonia

To overstate the case somewhat, if influenza kills you, it kills you by giving you pneumonia. It doesn't ordinarily kill you directly.

Your mistake seems to be that you think pneumonia is simply and only an independently acquired lung infection by pneumoccocus bacteria. If that were the case, then a vaccine for a virus would not be expected to reduce this singular bacterial infection.

But that's just one form of pneumonia. Pneumonia is a wide variety of lung infections or even physical lung damage that cause the lungs to fill with fluid, which in turn causes the patient to die of oxygen starvation.

Generally, the way flu kills is the virus damages the lung tissue, and this allows already normally present bacteria in the nose and throat to infect the lungs with a bacterial infection. It could be pneumoccocus or any of a variety of bacteria strains that ordinarily are harmless.

Your analogy of socks and rain therefore is wrong. The flu vaccine is indeed intended to prevent pnuemonia; it is intended to prevent flu deaths in the elderly, and flu deaths in the elderly are generally caused by, as a final factor, pneumonia.

The study says that administration of the flu vaccine is not statistically associated with reduced pneumonia incidence. That is very close to saying that the flu vaccine has little effect on reducing flu mortality.

In fact, the direct cause of death for a vast number of illnesses, including cancer, AIDS, and even malnutrition, is pneumonia. It's the disease that finishes off a huge proportion of very sick people.

[Orrex]

15. Thank you for the clarification

Incidentally, the socks analogy wasn't mine--I was just borrowing it.

[HamdenRice]

37. You're welcome, and it's always a pleasure to have a respectful discussion with you

Unlike you, some people on this forum seem incapable of disagreeing respectfully.

[Orrex]

44. Well, let's just say that you caught me on a good day

:evilgrin:

[TZ]

11. Influenza itself KILLS.

If you don't realize that, then you are sadly misinformed. Ask people who CAN'T be immunized how they feel about being at risk from being severely sick from the selfish and self centered people who think that not vaccinating only effects them.

[HamdenRice]

36. For a so-called scientist, you seem to get the science wrong a lot

Why doesn't our resident self proclaimed "scientist" know the elementary facts about the relationship between flu and pnumonia?

Well, I shouldn't say scientist. I should say "lab tech."

Whatever.

You also seem not to understand various kinds of public health vaccination strategies. For certain diseases, public health is enhanced by universal vaccination -- small pox, polio, etc. For other diseases, primarily people at risk are encouraged to get the vaccination -- influenza being one of them. So it is not "selfish" for healthy people not to get a flu vaccine. The reason you don't understand this is that you demonstrate over and over that you are incapable of comprehending cost/benefit analysis as it applies to vaccines.

http://www.nytimes.com/2004/11/03/nyregion/03flu.html

The Flu Kills, but Documents Rarely List It as the Killer
By MARC SANTORA

Published: November 3, 2004


The threat, not well understood outside the medical community, has been rendered with authoritative starkness since news broke of the flu vaccine shortage. Lives are at risk. Every year, we are told, influenza kills multitudes of vulnerable people, and the death toll is often repeated: 36,000 die annually in the United States alone.

The lethal efficiency of the flu has come as a surprise to many, it turns out, because almost no one is ever officially classified as dying of influenza.

There is no public national accounting of who had influenza listed on their death certificate. But of the roughly 2,500 deaths estimated by city health officials to have been caused by the virus in New York City in 2002, influenza was listed as the cause of death for only two people. The previous year, not a single death certificate listed it, according to city health records.

"It sets the stage for the susceptible host to crumble," said Dr. Jonathan M. Raskin, a pulmonologist in Manhattan.

The system by which the Centers for Disease Control and Prevention in Atlanta and the New York City Department of Health and Mental Hygiene come up with an average annual death toll for flu are the same and are relatively simple. Dr. Farzad Mostashari, an epidemiologist with the City Health Department, said that both the department and the C.D.C. look at the average number of pneumonia deaths during a given period and set them against what is known about flu activity during that period. When the flu is present, they check for marked increases in the number of pneumonia cases. All the cases above the average are attributed to the flu, he said.

<end quote>

http://www.nih.gov/news/health/aug2008/niaid-19.htm

Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic
Implications for Future Pandemic Planning

The majority of deaths during the influenza pandemic of 1918-1919 were not caused by the influenza virus acting alone, report researchers from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. Instead, most victims succumbed to bacterial pneumonia following influenza virus infection. The pneumonia was caused when bacteria that normally inhabit the nose and throat invaded the lungs along a pathway created when the virus destroyed the cells that line the bronchial tubes and lungs.

...

The work presents complementary lines of evidence from the fields of pathology and history of medicine to support this conclusion. "The weight of evidence we examined from both historical and modern analyses of the 1918 influenza pandemic favors a scenario in which viral damage followed by bacterial pneumonia led to the vast majority of deaths," says co-author NIAID Director Anthony S. Fauci, M.D. "In essence, the virus landed the first blow while bacteria delivered the knockout punch."

NIAID co-author and pathologist Jeffery Taubenberger, M.D., Ph.D., examined lung tissue samples from 58 soldiers who died of influenza at various U. S. military bases in 1918 and 1919. The samples, preserved in paraffin blocks, were re-cut and stained to allow microscopic evaluation. Examination revealed a spectrum of tissue damage "ranging from changes characteristic of the primary viral pneumonia and evidence of tissue repair to evidence of severe, acute, secondary bacterial pneumonia," says Dr. Taubenberger. In most cases, he adds, the predominant disease at the time of death appeared to have been bacterial pneumonia. There also was evidence that the virus destroyed the cells lining the bronchial tubes, including cells with protective hair-like projections, or cilia. This loss made other kinds of cells throughout the entire respiratory tract — including cells deep in the lungs — vulnerable to attack by bacteria that migrated down the newly created pathway from the nose and throat.

In a quest to obtain all scientific publications reporting on the pathology and bacteriology of the 1918-1919 influenza pandemic, Dr. Taubenberger and NIAID co-author David Morens, M.D., searched bibliography sources for papers in any language. They also reviewed scientific and medical journals published in English, French and German, and located all papers reporting on autopsies conducted on influenza victims. From a pool of more than 2,000 publications that appeared between 1919 and 1929, the researchers identified 118 key autopsy series reports. In total, the autopsy series they reviewed represented 8,398 individual autopsies conducted in 15 countries.

The published reports "clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory flora in most influenza fatalities," says Dr. Morens. Pathologists of the time, he adds, were nearly unanimous in the conviction that deaths were not caused directly by the then-unidentified influenza virus, but rather resulted from severe secondary pneumonia caused by various bacteria. Absent the secondary bacterial infections, many patients might have survived, experts at the time believed. Indeed, the availability of antibiotics during the other influenza pandemics of the 20th century, specifically those of 1957 and 1968, was probably a key factor in the lower number of worldwide deaths during those outbreaks, notes Dr. Morens.

[Hannah Bell]

40. Nother interesting point I'm sure the well informed science Sage knows:

viral & bacterial cycles run in tandem. Interesting environmental med area.

Nother point (as i'm sure sage knows:) poorly designed vaccination campaigns can increase deaths.)

[HamdenRice]

42. Didn't realize you had already posted the 1918 study

And yes, they don't understand how poorly designed vaccination campaigns can increase deaths. That's the basis for doing a cost/benefit analysis. For some reason, they seem to think that if you talk about cost/benefit analysis you are anti-science.

Go figure.

[Fire_Medic_Dave]

46. What are your medical credentials exactly?

[HamdenRice]

47. I don't claim any medical credentials

My professional area is development economics, so I've had to learn a lot about public health in poor countries, but I don't claim to have medical credentials.

But as an avid amateur follower of science, I'm certainly capable of seeing when someone doesn't understand the etiology of influenza and pneumonia.

[Fire_Medic_Dave]

50. Sounds good.

Just didn't know why you were picking on someone for being a "lab tech".

David

[WildClarySage]

21. Only to people I don't give a crap about.

I know the science. More importantly I know how to read a study and evaluate its significance. Something an awful lot of people here don't seem to get.

[Hannah Bell]

32. Gee, I wonder why Lancet published a study that examined such a non-significant, laughable question?

according to you, the person who knows how to read studies & interpret their significance.

I guess the folks at one of the big 4 medical journals just don't know what they're doing.
Obviously, they should look at whether flu vaccine reduces flu deaths. I mean, any person who knows how to read studies & interpret their significance knows that.

[HamdenRice]

38. What you mean to say is you don't give a crap about science

if it disagrees with your ill informed opinion.

See post 36. You obviously have no idea whatsoever what you are talking about.

[no_hypocrisy]

3. Before I stopped taking flu shots, I once took one with a pneumonia vaccine simultaneously,

one in each arm. Was that a mistake! (Not that I should have done both in the same arm, but rather wait a couple of weeks.) I couldn't lift my arms without the most amazing soreness for at least ten days.

I now stick to taking ecchinesia to fight a nascent infection.

[Fire_Medic_Dave]

4. You made up the title right?

From your article, "The effect of influenza vaccination on the risk of pneumonia in elderly people during influenza seasons might be less than previously estimated." This is a vastly different statement than your title suggests.

David

[xchrom]

7. of course she made it up.

just like she was being -- um -- disingenuous{to be polite} about the correllation between being vaccinated for flu season and pneumonia.

this is a prime example of the scary lunacy of anti-vaxers.

[Hannah Bell]

10. it's direct from the findings, & pneumonia is a frequent complication of flu.

reducing incidence of pneumonia is one of the ways vaccination supposedly saves lives. most flu deaths aren't directly due to "influenza," you know.

you're really too knee-jerk. i'm not an "anti-vaxer". i work in a hospital & have 2 advanced degrees.

Influenza Vaccine May Not Protect Elderly From Pneumonia CME/CE
News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD

"Pneumonia is a common complication of influenza infection in elderly individuals and could therefore potentially be prevented by influenza vaccination," write Michael L. Jackson, PhD, from the Group Health Center for Health Studies in Seattle, Washington, and colleagues. "In studies with data from administrative sources, vaccinated elderly people had a reduced risk of admission for pneumonia compared with unvaccinated seniors... but....etc

[TZ]

12. bullshit

Tell me immunocompromised people (and there are ALOT around) aren't at risk from influenza..passed on by unvaccinated people?
For someone who CLAIMS to be not an anti-vaxxer, you sure sound like one.

[Hannah Bell]

16. i didn't say no deaths occur from flu. i said most flu deaths don't

occur from flu itself.

& "immunocompromised" isn't a very useful term in this context. too wide a net. for example, "immunocompromised" would apply to the person whose immune system wouldn't produce antibodies in response to vaccine, i.e. vaccination would be useless.

you're saying there are immunocompromised persons who respond to vaccine but are nevertheless at risk from unvaccinated people...makes even less sense.

[xchrom]

14. ...

"The effect of influenza vaccination on the risk of pneumonia in elderly people during influenza seasons might be less than previously estimated."

[Hannah Bell]

18. Read the FINDINGS - the actual CONCLUSION of the RESEARCH ITSELF.

From which I took the post word for word.

"FINDINGS: 1173 cases and 2346 controls were included in the study. After we adjusted for the presence and severity of comorbidities, as defined by chart review, INFLUENZA VACCINATION
WAS NOT ASSOCIATED WITH A REDUCED RISK OF COMMUNITY-ACQUIRED PNEUMONIA (odds ratio 0.92, 95% CI 0.77-1.10) during the influenza season.

[Fire_Medic_Dave]

27. The conclusion would be the interpretation not the findings.

[Fire_Medic_Dave]

28. See you finally represented it accurately, it wasn't that hard.

[Hannah Bell]

33. no, conclusion of the research is findings. interpretation is conclusion of the

reseachers. it's a subtle point.

[Hannah Bell]

8. it's the findings, not a "title".

FINDINGS: 1173 cases and 2346 controls were included... influenza vaccination was not associated with a reduced risk of community-acquired pneumonia (odds ratio 0.92, 95% CI 0.77-1.10) during the influenza season.

[Fire_Medic_Dave]

13. That's not what your title says.

This is from your article, "The effect of influenza vaccination on the risk of pneumonia in elderly people during influenza seasons might be less than previously estimated."

So you changed the statement in the findings for your title and ignore the interpretation. What are your advanced degrees in and in what capacity do you work in a hospital?

David

[Hannah Bell]

17. i said, it's in the FINDINGS.

"FINDINGS: 1173 cases and 2346 controls were included in the study. After we adjusted for the presence and severity of comorbidities, as defined by chart review, INFLUENZA VACCINATION
WAS NOT ASSOCIATED WITH A REDUCED RISK OF COMMUNITY-ACQUIRED PNEUMONIA (odds ratio 0.92, 95% CI 0.77-1.10) during the influenza season.


Now please tell me what I've misrepresented. That is the FINDING, the CONCLUSION of the research ITSELF.

[Fire_Medic_Dave]

19. Your title leaves out community acquired.

You also said it's the findings now you say it's in the findings.

David

[Hannah Bell]

20. psst: because there are only so many spaces in the heading.

"is the findings" & "is in the findings" are pretty much the same thing, since the findings is about 3 lines.

"community-acquired" = they got flu outside an institution, not in a hospital or nursing home or something. big whoop, doesn't change the FINDINGS.

i thought you were interested in data rather than game playing. am i wrong?

[Fire_Medic_Dave]

22. There is a vast difference in all of those statements.

You said, " Flu vaccination not associated with reduced risk of pneumonia"

The data shows that the reduced risk might be less than previously estimated for a specific type of pneumonia.

It's the finding means it's the actual findings not your edited version of it.

It's in the findings could be what you actually did which was edit the actual findings.

I am interested in the data and it looks to me like it should be recommended that people in high risk groups should get the pneumonia vaccine in addition to the flu vaccine. Based on the data would you disagree with that statement?
Once again what are your advanced degrees in and in what capacity do you work in a hospital?

David

[Hannah Bell]

23. what were the findings?

done. Understand the difference between FINDINGS (objective) & INTERPRETATION (subjective)?

FINDINGS: 1173 cases and 2346 controls were included in the study. After we adjusted for the presence and severity of comorbidities, as defined by chart review, influenza vaccination was not associated with A reduced risk of community-acquired pneumonia (odds ratio 0.92, 95% CI 0.77-1.10) during the influenza season.

INTERPRETATION: The effect of influenza vaccination on the risk of pneumonia in elderly people during influenza seasons might be less than previously estimated.



I'd thought you were a bit more fair-minded than your associates & wouldn't bother with cheap bullshit like "you didn't put 'community-acquired' in". Apparently not.

[Fire_Medic_Dave]

24. Not what you said they were!

Here are the findings: influenza vaccination was not associated with a reduced risk of community-acquired pneumonia (odds ratio 0.92, 95% CI 0.77-1.10) during the influenza season.
I noticed you failed to answer either of my questions. I wonder why.

David

[Hannah Bell]

25. You wonder why? Because omitting "community-acquired" doesn't

materially change the findings, & that kind of nit-picking while avoiding the meat of the findings is cheap shit, as is the "you invented the title" bullshit.

I'm not interested in playing dueling diplomas with "fire medics."

[Fire_Medic_Dave]

26. You do realize there are different types of pneumonia?

It is likely that an elderly patient who gets a flu vaccination would have a greater chance of not contracting hospital acquired pneumonia. Since patients who get the flu vaccine are more likely to not contract the flu and if they do it's likely to not be as severe, thus not requiring hospitalization, thus making them less likely to not contract hospital acquired pneumonia. How about answering the other question? By the way, I'm sure you are far more educated than I am even if it is a business degree.

David

[Hannah Bell]

31. Of course I realize there are different types of pneumonia.

I also realize it can be acquired in different locations, which is what you're talking about.

The study looked only at community-acquired infections. It didn't look at hospital acquired pneumonia, so your speculations as to what "might" be the case with hospital acquired infections are beside the point.

I'm sure you're competent & educated in your field of expertise. But if you're a medic, that expertise has nothing in particular to do with vaccines. Neither does mine. I've discussed my credentials before: I'm a clinical dietitian, MS,RD. I interned at a research hospital, I've worked ICU, peds/maternity, nicu, cardiac, geriatric, etc. & I've done clincal human subjects research - but not on vaccines.

So on that level, neither one of us should be flashing the "education/experience" card. I wouldn't have mentioned mine had it not been for the number of times others have attacked on that basis - I/others don't love gardasil so are anti-science fundie faith-healers, or something similar. (Including one person who then bragged about getting an "A" in A&P - so VERY impressive! - it is to laugh.)

I try to debate evidence, not degrees. There are plenty of sharp folks with no university ed. And plenty of folks with degrees or credentials who adopt the assumptions of their guilds without much real questioning or thought. I know & work with medics, nurses, doctors, x-ray techs, med techs, drug reps, etc. So I know where their competencies are & what their education consisted of, & where I'm their peer & where I'm not.

I know that the "average" one - including docs - has no specialized expertise in vaccines or immunology that gives them a superior position from which to sneer at folks with concerns or questions, or justifies the kind of stupid, knee-jerk, nasty personal attacks I see on these threads.

[Hannah Bell]

35. I honestly don't understand what your point is.

They looked at a population of free-living HMO members 65-94 y/o.

They identified 1173 "cases" - folks who got pneumonia IN THE COMMUNITY & were then treated for it, either as outpatients or inpatients.

Each case was randomly matched to two controls who hadn't gotten pneumonia.

They found people who'd been vaccinated were as likely to have gotten pneumonia as the non-vaccinated, given similar risk factors (this is what the adjustments for comorbidities, etc. were about).


Furthermore, per UK NHS analysis, findings included:

"Further analysis of subgroups found NO EFFECT of vaccination on infection during the peak season, ON RISK OF HOSPITALIZATION, or on risk of infection in one of the flu seasons included in the study (2000, 2001 or 2002)."

http://www.nhs.uk/news/2008/08August/Pages/Flujabandpneumonia.aspx



You're making some big deal out of my omitting "community-acquired". You could have just as well said I omitted "65-90 y/o," "relatively healthy, non-immunocompromised," & other limiting variables that made the findings less than universal.

Furthermore, you ignored the most important word in the title, the one that clearly shows no intent to mislead: "associated," which, in research jargon, has a specifically limited meaning.

Do you think CDC recommends & prioritizes flu vaccination for EVERYONE OVER 50, most of whom live in their own homes IN THE COMMUNITY & are relatively healthy, mainly to reduce HOSPITAL-ACQUIRED flu & pneumonia?

Or did you think some of the folks in this study got their pneumonia AFTER they entered the hospital?

Or would you have preferred to read a study of hospital-acquired pneumonias among the vaccinated & unvaccinated instead?

I repeat: "community-acquired" is the default assumption, the "normal case". It was a more serious "distortion," if that's how you wish to view it, not to mention "65-90 y/o."

My default assumption was people who were interested would read the text, which was posted in full without any intent to mislead.

But I forgot, this is DU, where people nit-pick stupid shit while postulating about what's "likely" or "not likely" based on their own biases, irregardless of the relevance to the data presented.

[Fire_Medic_Dave]

45. My point is simple.

The researchers who published the paper you cited felt it important to include "community acquired" in the findings. You didn't feel it was important. You said you left it out because it didn't fit, but it did fit as I have proven. So my point is be very specific and as detailed as possible when quoting actual published papers because those little phrases that you leave out may have some implication to the overall results.

David

[Hannah Bell]

48. Lancet. 8/08: Flu vaccination not associated with reduced risk of pneumonia

i don't know what to tell you. tried it again, & that's all that fits in my subject line. yes, your point is very simple. sorry i bothered.

[Fire_Medic_Dave]

51. My apologies then.

That's kind of weird, I assumed there was a set number of spaces.

David

[Fire_Medic_Dave]

29. Lancet. 8/08:Flu vaccination not associated with a reduced risk of community-acquired pneumonia.

pssst: I think you just got caught.

David

[Fire_Medic_Dave]

30. BUSTED

[Hannah Bell]

34. Your comments show you didn't understand the paper, so I'm not sure why I'm busted.

>>You said, " Flu vaccination not associated with reduced risk of pneumonia"

The data shows that the reduced risk might be less than previously estimated for a specific type of pneumonia.<<


"Community-acquired" = acquired in normal life, i.e. majority of cases.

Not acquired AFTER being admitted to a hospital for another condition.
Not acquired by residents of a penal institution, nursing home, orphanage, etc.


The finding is: the risk of pneumonia was not reduced in the vaccinated group, i.e. there was no statistically significant difference in incidence of pneumonia between the vaccinated group (case) & unvaccinated group (control) in this study.

The interpretation is: the benefits of flu vaccination may be less than previously thought (yes, specific to "community-acquired" illness, i.e. for most people.)


Community acquired pneumonia that results in hospital admission is still "community-acquired". You seem to think inclusion of out-patients & in-patients has some significance re "community-acquired". It doesn't. Both in & out-patients sought treatment for pneumonia acquired in the general community.

"Community-acquired" is the default case. It's assumed unless otherwise specified.

"Non-community-acquired" = acquired inside an institution: that's the special case.

[HamdenRice]

39. You're wasting your time

The person you are arguing with has no intention of trying to understand the study but is instead engaging in the "strategic nit pick," a common internet poster strategy for avoiding discussing the substance.

You might find post 36 interesting.

[Hannah Bell]

41. My stupidity, then. I thought he actually cared about the science

& was just a little weak on the research angle.

Should have known, rehashing stuff the 4th time.

[Fire_Medic_Dave]

43. You said the findings wouldn't fit in the title, they did, hence BUSTED.

[Hannah Bell]

49. see 48.