Aug 7Liked by PulmCCM

Excellent article. I am an intensivist. I haven't seen ANY cases of vaccine related myocarditis but don't doubt that it exists. I just haven't seen any. My experience was that the initial vaccine worked extremely well, but then became less effective with time, virus mutation, etc...

I have been shocked, however, with how the public has lost its trust/respect for the healthcare industry. Family, friends, neighbors, etc..... many are convinced the vaccine NEVER worked and the mandates were just a scam / power-play. Unfortunately, I think there is some truth to that. If something like this happens again (and I think it is inevitable), society is in real trouble.

I am a new member and enjoy your stuff. Thanks.

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Aug 8Liked by PulmCCM

Pandemics are political events. I suggest that everyone who is having a strong emotional reaction to this post read Nicholas Christakis’ “Apollo’s Arrow” or John Barry’s “The Great Influenza” --both helped me contextualíze the erroneous messaging from public health agencies (school closures, for example) and the extreme resistance to vaccination/treatments we observed from a large swath of the public.

Here’s the thing...when trust in American public institutions (medicine included) is at an all time low and the messaging from the institutions seems glib and fails to acknowledge nuance or uncertainty, people will go elsewhere--like Joe Rogan--for information/validation/ advice.

The messaging and policy on vaccinations sucked. I consider the day I received my second dose of the Pfizer mRNA vaccine to be one of the best days of my life. I am happily boosted....but I would have appreciated more honest information with regard to the risks when vacccinating my 11year old son. And I say all this as an Intensivist who provided care in four different states during the COVID surges who is married to an Emergency Physician.

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Pulm/ Critical Care for 30 plus years. Critical thought processes have been suppressed by our medical institutions and media. We should all listen more to Joe Rogan, Paul Marik, Peter McCoullar, ......

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Long-time listener, first time caller, as the expression goes. I agree with the writer about the need to entertain opinions, openly and honestly, that lay outside of the mainstream, as long as they avoid the ad hominem nonsense and conspiracy talk. There is valid reason to question the benefits of, for example, school closures in the pandemic. I supported it early on; now, I am not so sure. I personally gave a talk at a major CCM meeting in February 2020 where I recommended against steroids for Covid. This was early, all we had was data from SARS and H1N1, and it was the best guess I could make. It was incorrect. My conscience can live with this.

I suppose my concern is the writer's assumption that CDC and NIH were acting nefariously. I think we all recall that these were desperate times. It is reasonable to assume that everyone reading this blog was hip-deep in dying patients with Covid. Not every call from public health authorities (and it is worth noting that it wasn’t just CDC and NIH, it was countless public health agencies around the world) was going to be correct. The original writer for the site, in my opinion, is doing us a disservice by ascribing ill intent where simple error would suffice as an explanation. (I realize the writer said they deleted words about "promoting lies or craven manipulations", but posting it in the chat is a bit disingenuous.)

The myocarditis incidence from the vaccine versus from Covid is going to vary wildly based on host immunity and the incidence of viral infection. I have no specific insight into the CDC’s internal deliberations at the time, but I posited this at the time and used this line of reasoning in my own practice: Covid with myocardial involvement is often a lethal disease, and my ICU was 30-deep with intubated and/or dying patients. What it was not 30-deep with was young healthy men with vaccine-associated myocarditis. Many of those intubated patients were quite young; yes, they did often have comorbidities, but not always. But vaccination in those days was quite likely safer, maybe not by as much as we’d like, but still safer.

My time in the military overlapped with the first 18 months of the pandemic, including widespread vaccine availability for military personnel (that is, lots of men under 40 with few chronic medical conditions). We saw a couple of folks with vaccine-associated myocarditis, sure, but they improved rapidly with NSAIDs and went home. (This is not the first time we’ve dealt with this in the military; the pre-Jynneos smallpox vaccine did the same thing.) I don’t wish to downplay myocarditis per se or the discomfort it causes, but vaccine-associated myocarditis is a comparatively benign event in most patients. I don't have the numbers in front of me, but I will bet a shiny nickel that ICU admissions from vaccine-associated myocarditis are very rare. When Covid was running rampant and most people lacked immunity, their odds of getting infected were high, and the math favoring vaccination for young adults made sense.

On the other hand, my last two clinical acts in the Navy were to do a tracheostomy on an active duty man who had refused vaccination, followed by talking a colleague in a community hospital through the management of another active duty servicemember who’d refused the vaccine and then ultimately died despite aggressive care at a premier center. So I have definitely seen more young, healthy men have horrific outcomes from Covid than I have seen even mild cases of vaccine-associated myocarditis. Anecdotes are not data, but I doubt my anecdotes are unique.

But now it’s mid-2023. We’d be hard-pressed to find someone without anti-spike antibodies, and Covid is nowhere near as prevalent as it was. (This is of course in part due to vaccine policies encouraged by CDC and NIH.) Today, even I find myself softening about vaccine mandates. If you’re a doctor or an ICU nurse, then yeah, roll up your sleeve and do your duty. But for a college student? Probably not worth the mandate anymore. The risk-benefit ratio has shifted. I still recommend it, but I won’t make a thing about it anymore. So I agree with the basic notion here: a young man (or woman, or old man, or young M2F TG woman, or whomever) should be offered Covid vaccination along with up-to-date counseling based on the best available evidence, which includes the data discussed by the writer. And if they decline vaccination, well, OK then. I thank them for hearing me out and then move on.

I do have a pet theory about the loss of public trust. I attribute some of it to misinformation, often deliberate misinformation, but I also wonder about the impact of the public seeing the scientific process play out on the news in real time. Normally, we have these debates in settings where the public doesn't notice. You don't see CNN or Fox News weighing in on high- or low-volume crystalloid resuscitation or about LR vs NS vs albumin. But we were doing Covid science and setting policy in full display of the public. It brings to mind Bismarck's quote about making sausage.

As for the call in the chat to listen more to Joe Rogan: I enjoyed him on NewsRadio quite a bit back in the day, but I will go elsewhere for health advice and critical assessments of the literature, thank you. Paul Marik, a man I once admired as the rest of us did, lost me during the whole vitamin C/sepsis thing (which I took seriously for a much longer time than I would have if it hadn't been Paul Marik advocating it). And Peter McCullough has been quoted as saying that natural Covid infection induces permanent immunity, a fact which is clearly disproven.

Everyone is wrong sometime; I listed some of my errors above, and I'm sure there are others (and I am basically a nobody, so who cares). I will be happy to listen to these folks anew when they start to talk about their scientific errors as well. They are smart people, and I hope they have more to contribute in the future.

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Thank you for covering this. This is one of the very few academic/medical platforms that has taken a go at it.

This is helpful and first of many steps needed to restore our faith in evidence based medicine.

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This article states that vaccination associated myocarditis incidence is higher than COVID-19 myocarditis. The Circulation article does not say that. It finds specifically that myocarditis rates are higher after a Moderna booster than viral infection, but only that single situation. Pfizer and adenovirus vaccines have lower rates than viral infection in all circumstances that I can tell, as well as initial Moderna vaccination.

Have I misunderstood this?

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Thank you

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Thank you for your honesty. As an ER doc that still has PTSD (figuratively) from the COVID nightmare, my inclination was to treat patients as best I could instead of sending people home with nothing and telling them to come back "when your lips are blue". That was a travesty. I used Peter McCullough's protocol sometimes, and Paul Mariks protocol sometimes. Who knows how many people got better (based on anecdotal follow-ups, many people did get better). At the very least, people were thankful to get something, and that alone (placebo effect? hope?) could have contributed to their getting better.

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