Should young men still be required to get vaccinated against Covid?

Between one in 3,000 and one in 20,000 healthy boys and men aged 12-24 vaccinated against SARS-CoV-2 experienced myocarditis severe enough to require hospitalization, often in the ICU, and a minority still had symptoms and abnormal cardiac MRIs at the time of discharge. It’s unknown how many more experienced myocarditis not severe enough to result in hospitalization.

Their risk for myocarditis from the vaccine was higher than their risk from myocarditis from Covid, although they were told otherwise by U.S. public health authorities. Many are still today required to get the vaccine in order to work or attend college. Those who object are criticized as “anti-vax” or condescended to as the brainwashed marks of disinformation-spewing podcasters. Can reality be found amid this mess?

The original basis for mandating vaccines for healthy young people was the reasonable presumption that getting vaccinated would prevent the spread of Covid, benefiting the vulnerable and preserving health system capacity. In early 2021, as hospitals overflowed, deaths mounted, and the economy languished, these felt like vital national goals.

But by mid-2021, it was known that vaccination only reduced transmission by about one-third in the highest-risk exposures from infected household contacts (25% of the vaccinated still become infected, vs. 38% of the unvaccinated). And surprisingly, the vaccination status of the person bringing Covid home did not matter with regard to transmission. That’s right: your fully vaccinated spouse with mild Covid is just as likely to transmit an infection to you as your unvaccinated visiting brother-in-law who caught it at the airport (25% vs 23%). Throughout the pandemic, fully vaccinated people have commonly become infected (usually mildly), thence transmitting SARS-CoV-2 similarly often as the unvaccinated. Reducing the severity of illness after infection is what the vaccines are so amazingly, miraculously good at, not prevention of transmission.

Besides being incredibly effective at reducing severe illness, the vaccines were shown to have very low adverse event rates, except in one demographic group. In late 2021 young men’s risk of myocarditis was confirmed to be up to 6-fold higher from the Moderna vaccine than from Covid itself:

In men younger than 40 years old, the number of excess myocarditis events per million people was higher after a second dose of mRNA-1273 than after a positive SARS-CoV-2 test (97 [95% CI, 91–99] versus 16 [95% CI, 12–18]). (Circulation)

Pfizer’s vaccine was also found to cause myocarditis in young men in that study, at roughly the same rate as Covid infection.

Yet CDC was claiming the opposite in its Morbidity and Mortality Weekly Report around the same time. As concerns for increased myocarditis in young males surfaced, CDC published this reassuring infographic:

But it appears to have been inaccurate, based on data generated by a single structured EHR query administered at 40 U.S. health systems. European health officials were first to identify the actual risk, because U.S. vaccine postmarketing surveillance systems were (and are) underpowered to detect safety signals. In Scandinavian countries, young men were found to have an 18-fold risk for hospitalization after the second Moderna shot. The risk after the Pfizer shots was lower than Moderna’s, but still substantially elevated. CDC didn’t mention the concerning European data in its report, but erroneously cited some of that data in its MMWR report as agreeing with its findings, when it actually showed the opposite: higher myocarditis risks after Moderna vaccination than after Covid in those under age 40.

The American Heart Association helped downplay the risk story for young males under the headline “Covid-19 infection poses higher risks for myocarditis than vaccines” — but in the 12th paragraph, way below the fold, noted that just the opposite may be true for their demographic. As late as May 2023, Yale myocarditis researchers continue to preferentially cite the CDC MMWR data for young men, ignoring the stronger and clearer risk signal from European data.

We didn’t know all this in 2021. And in the midst of a global pandemic, with science evolving in real time, allowances must be made for the messiness of reality and data. Some would say it’s unfair to judge these things retrospectively.

But well after it became clear in 2022, Covid vaccine mandates persisted, and continue at a large number of U.S. university campuses. Can this still be justified?

True, a less than one in 3,000 risk for an adverse event is rare. And keeping things in perspective, the total number of young men hospitalized for myocarditis due to SARS-CoV-2 vaccination is probably in the thousands, during a years-long pandemic causing millions of deaths globally.

But the policy calculus changes when a healthy person is required to take a risk to pursue ordinary life goals (e.g. education), despite a very low individual risk from the virus itself, and despite diminishing benefits to others as the virus becomes endemic.

(The true vaccination benefits in healthy young people remain poorly understood, because of decisions by industry and public health officials not to report out young people’s outcomes data separately. Generally speaking, they’ve been lumped in with older adults, making vaccination’s benefits in those aged 40-65 appear lower, while falsely inflating vaccination’s benefits in the young.)

We shouldn’t dismiss healthy young men who were or are vaccine hesitant (many of whom were already infected, with sufficient immunity to prevent severe illness on subsequent infections) as “anti-vax” or antisocial. It’s entirely possible that getting two doses of a Covid vaccine in two weeks, particularly Moderna’s, has a higher chance of putting them in the hospital than Covid.

The initial vaccine mandates felt defensible when the data were unclear, the virus more deadly and health systems overwhelmed. And there are still good reasons for healthy young men to choose to get the vaccine despite the low risk of myocarditis: reducing the chance of severe illness, or losing one’s smell sense, or long Covid symptoms, or to avoid lost income from missed work, or even wanting to do everything possible to protect others (this last being the least compelling, given the vaccine’s moderate performance at reducing infection and transmission). Young men who are obese or who have any health condition have even stronger reasons to get vaccinated against SARS-CoV-2. Myocarditis risks today are probably even lower than previously: time between the two vaccine doses can be lengthened to eight weeks. Some young men, with their primary care physicians, have opted for forgoing the second dose, and choosing Pfizer’s over Moderna’s shot.

All that being said, it’s hard to argue the societal benefits today are sufficient to continue to require healthy boys and young men to take a risk of hospitalization from myocarditis just to be allowed to participate in public life. Exceptions might include those working in healthcare, with the elderly or immune suppressed, etc.

Health officials, university administrators, athletic organizations, policymakers and corporate managers (none of whom read this blog) take note: a young man sickened by a mandated vaccine he didn’t want, in today’s lower risk environment, after being misled about the relative risks, will probably be angry. Maybe even enough to listen to Joe Rogan.

Addendum:

I wasn’t expecting this post to be controversial - I tried to stick very close to the data and away from any opinion. My opinions don’t matter!

But based on some responses I got, I feel the need to clarify in case this gets shared more widely by people without an interest in fairness:

I’m grateful for all the CDC has accomplished throughout its existence.

I need the CDC.

We all need the CDC.

And it’s vital that the public feels like we can trust CDC—for everyone’s sake.