How Myocarditis Influences Vaccine Mandate Decisions
Monday is usually the Study of the Week. This week I argue that SARS-CoV-2 vaccine mandates are wrong.
Your heart beats about 100,000 times per day. Its reliability makes it easy to forget the necessity of the rhythmic beating. Until something happens.
Myocarditis is inflammation of the heart, which can lead to problems in either the acute or chronic phase.
The acute phase may include symptoms such as chest pain. The ECG can show signs of injury; cardiac enzymes are elevated, indicating cell death, and an ultrasound may show decreased heart function.
In most cases, this resolves with supportive care and rest.
In some cases, it does not resolve. And the heart can fail.
The chronic phase of inflammation includes the laying down of scar. Think of when a skin wound heals; there is scar. Scar in the heart can cause problems because it disrupts the normal flow of electrical activation (think rocks in a stream).
In most cases, scar does not cause issues. For instance, most people who have a defibrillator implanted because of scar tissue in the heart never have a rhythm disturbance that requires a shock.
In some cases, scar does cause issues—often rhythm disturbances. And these can be severe. In this seminal paper, myocarditis was the third leading cause of sudden cardiac death in young competitive athletes.
The core problem with myocarditis (of any sort) is the asymmetry and unpredictability of risk.
Yes, most patients with myocarditis recover. Yes, the incidence of myocarditis after a viral infection is low. Yes, the incidence of myocarditis after a mRNA vaccine is also low.
Incidence is not the problem; the problem is that sometimes myocarditis can be horrible. And there are few if any predictors.
You can’t avoid myocarditis from viral infection. There are many viruses that can lead to myocarditis. It’s not only SARS-CoV-2. Before 2019, everyone lived with a low baseline risk of viral myocarditis. We did so because it was not a modifiable risk.
The risk of myocarditis from a mRNA vaccine is modifiable.
Now we need to pause. This is the part of the post that requires rational thinking. Let’s write out the obvious.
Messenger RNA vaccines made a big difference in 2021 and early 2022. I saw it first-hand. After January of 2021, the vast majority of severe COVID-19 cases were in people with risk factors who did not take the vaccine.
Another thing I saw first-hand: there were almost no college-aged persons with COVID-19 who needed oxygen or ventilators. SARS-CoV-2 has a steep age gradient for severe disease.
That was then. Now I see something different.
The pneumonias and severe COVID-19 illness are nearly gone. It’s weird. In a matter of months, almost all of our SARS-CoV-2 positive patients are hospitalized for some other reason. Again, that’s not to say there are zero SARS-CoV-2 pneumonias, but it is rare.
The explanation for the disconnect between positive tests and severe disease could be vaccination, increasing immunity, changes in the virus, or some combination of these. It doesn’t matter why. What matters is that SARS-CoV-2 seems more like a regular coronavirus now. Danish authorities have said publicly what hospital-based doctors know.
Another obvious fact: vaccines for SARS-CoV-2 can cause myocarditis. The overall incidence is low. But the greatest risk concentrates in young males.
Studies that cite the incidence of vaccine myocarditis of ≈ 1 in 100,000 are both true and misleading. It’s misleading because there is also an age gradient for vaccine myocarditis. A young male has a many-fold higher risk of vaccine myocarditis than an older female.
One final fact: SARS-CoV-2 vaccination does not prevent infection nor stop transmission.
Many studies support this fact. I am most drawn to the data from Portugal. Portugal was one of most vaccinated countries, yet, it had a clear surge of SARS-CoV-2 infections and hospitalizations.
The vaccine’s inability to stop infection and transmission renders the decision to take a SARS-CoV-2 vaccination a personal decision not a societal one—like the choice to avoid smoking and exercise regularly.
Now we can combine these statements to consider the decision to coerce young people to take additional vaccine shots—as is being done on many US college campuses and in the military.
In late 2022, a young person (without severe health issues) has a near-zero risk from SARS-CoV-2. They were very low risk in 2020-2021, but it’s even lower now.
Yet a young person has a finite risk from vaccine myocarditis. The risk for a vaccine myocarditis after a booster in a male may be in the order of 1 in 10,000 but if you have 466,000 military recruits last year, you are forcing 46 healthy people to get a disease that may have serious complications.
A study from Thailand found a 2.3% incidence of cardiac enzyme elevations after a second dose of mRNA vaccination in adolescents. A similar study from Swiss authors presented at the European Society of Cardiology meeting in August reported similar numbers after a booster vaccination. (We need more studies of this sort,)
These benefit/harm calculations form the core of medical decision-making.
Humans feel differently about statistics, so clinicians try to align decisions based on what patients feel are best for them.
Some patients would fear the viral infection and choose to get another booster vaccination. They might be worried about the risk of myocarditis from SARS-CoV-2 infection, though the incidence of that is hard to sort out.
(This recent study of unvaccinated patients in Israel found “no increase in the incidence of myocarditis and pericarditis in COVID-19 recovered patients compared to uninfected matched controls.”)
Other people would have greater fear from vaccine myocarditis and avoid the booster.
Given the current facts, I see no justification to prevent this normal decision making.
In 2022, SARS-CoV-2 vaccine mandates are wrong, and I oppose them.