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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 7, 2023·edited Aug 7, 2023Author

Thanks for commenting. I haven’t seen or even heard of any myocarditis cases either. I assumed it was all disinformation and nonsense or a tiny issue that was blown up by podcasters. The data is hiding in plain sight, in high impact journals. I supported mandates (possibly selfishly I admit) and we all depend on the CDC and it makes me sad and disappointed to see how this issue was handled.

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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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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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On reading some extra comments from the original writer here in the chat, I should add that it is clear that their opinions are more nuanced than the original post suggests. Nonetheless, I do stand by my observations here but welcome the chance to chat more about them if desired.

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Aug 8, 2023·edited Aug 8, 2023Author

Thank you for these great comments. And for making the tough calls when asked.

I don’t think CDC was nefarious. I think they were selective in what information they chose to share and when and how they shared it. Which they need to be up to a point. They aren’t a data clearinghouse. But read the mmwr report in its entirety. To publish a big shiny graphic saying the myocarditis risk is 7x favoring vaccination when European data was apparently available suggesting the 180 degree opposite — without mentioning that range of uncertainty / possibility — and even citing one of those papers misleadingly in the mmwr report (that paper says in its abstract and conclusions it found the vaccine risks were higher under age 40, but the CDC cites it saying it agrees with their conclusion that risks were lower) - this goes beyond simple error to me. Or if it is an error, it is so careless as to be problematic.

The post makes a big distinction between “then” and “now”. Maybe it rambles but the central thesis is limited to whether mandates should persist in young men.

Im not trying to put the CDC on trial. Only to mention how in this single instance, their mmwr report helped fuel an incorrect counternarrative to what now appears to be the truth, and continues to do so (see Yale, AHA, et al continuing to cite it).

I love the CDC, I need the CDC, we all need the CDC. We need the public to trust the CDC!

I agree vaccine induced myocarditis was not and still is not a huge deal medically or public health wise. I also make that clear in the post. (That’s why it was a side issue like you correctly say, back in the bad days.) About 20% of the recorded cases ended up in the ICU though. (See the linked papers in the post).

Rather than attacking the CDC my intent is to discuss their influence on the ongoing mandates ; transparency / honesty and regaining public trust. Even CDC has admitted it misstepped. Thats all forgivable. At least by me. They had good intentions. We just have to find a way back. Calling things out — I hope fairly — might be a helpful step in that direction.

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Aug 8, 2023Liked by PulmCCM

I hear you, and thank you for the thoughtful reply. Your central thesis is well-defended regarding the current mandates.(And if you think you rambled, take another look at my original post above.) I suspect that we agree more than we disagree, and those disagreements are productive and fruitful ones that advance the discussion and the science. Once again, my gratitude for your consideration.

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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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Aug 7, 2023·edited Aug 7, 2023Author

I would say that information and the larger narrative - what gets discussed and how - are strongly influenced and circumscribed by the institutions and media as you suggest. And this limits the range of mainstream thought and public opinion. Behind that, a small number of people at NIH and university chairs effectively control the research agenda, dictating what is allowed to be studied and what emerges as consensus knowledge.

None of this is inherently nefarious to me. By necessity, there needs to be some centralization of these processes, and power will naturally accrue to those entrusted with that authority.

The problems come when those wielding such outsize influence begin to pursue selfish or narrow minded political agendas. Enforcing orthodoxies. Suppressing rival questioners and nascent alternative paradigms. All this corruption is inevitable, but it’s a matter of degree. The only checks on this degrading and dangerous (to society) process ultimately are personal and institutional/cultural integrity. But today the systems we most rely on to have integrity - journalism, science - are openly, sometimes proudly abandoning it.

I disagree that this means we need to turn to these alternative sources. Most of them are far less reliable and more dangerous. Because rather than having a flawed internal calibration system that tends toward integrity , there is NO regulating tendency or accountability for integrity. In fact, just the opposite. These entities are rewarded with attention (clicks, eyeballs, ad impressions, media interviews, status, $$$) for provocation, which usually means abandoning any heartfelt and humble search for truth. For every important truth that gets uncovered, “they” (considered perhaps unfairly as a group) promote theories for which they don’t seem to have strong evidence, but do elevate their apparent status as somehow having access to alternative knowledge being suppressed by the mainstream sources.

The fact that these alternative sources have become so important - by occasionally bringing

important truths to light - is not to me an argument for their worth so much as a sad commentary on the corruption and failures of the aforementioned “mainstream” cultural institutions.

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Great article. This needs to be shared far and wide. The alternative sources cited above were all trying to voice their esteemed medical opinions during the pandemic, yet they were censored, and fired from their jobs. They did bring much truth to light. More than just occasional. They were labeled "conspiracy theorists" by pretty much everyone in "ivory tower medicine". They were saying exactly what you said above about the institutions and media; and the abandoning of integrity, journalism and science. Paul Marik is one of the most published CCM authors in his long career -- so we should call him a conspiracy theorist? Peter McCullough is one of the most published cardiologists in the world... so he's just a snake oil salesman? What are the lies that they promoted? Please elaborate. We are all interested in the truth, and since we can't get the truth from mainstream sources because of the corruption as you know, then why not have an open debate? Instead of just blowing them off and calling them names.... put your money (or your brain) where your mouth is and debate them with your evidence of malfeasance/wrong-doing. If you say, "I don't have time to debate conspiracy theorists" (or whatever label you apply to them), then you are just as guilty as all the institutions and media in censoring opposing viewpoints.

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Aug 7, 2023·edited Aug 8, 2023Author

You’re right. I deleted part of my comment saying that some bad actors were “promoting lies or craven manipulations” - because I don’t have evidence for it. All I have to go by is randomized trials. I don’t have the expertise or any special knowledge to conclude or comment beyond that.

There has been a lot of attention seeking by those challenging the mainstream. I don’t call them conspiracy theorists but it makes me uncomfortable and skeptical, especially in cases where the attention is being monetized or otherwise capitalized upon. That being said, everyone has an agenda. Me too. There is a broad spectrum there and we’re all flawed humans and it’s unfair and wrong to paint everyone with the same brush.

I hear a lot of certainty and righteousness from people expressing strongly held beliefs about specific therapies or political realities - and all that feels inconsistent to me if the point is to be skeptical and open to discussion. I’ve done it too. It feels good but it takes us away from where we should be heading together.

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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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Aug 8, 2023·edited Aug 8, 2023Author

Thank you Tariq. Unfortunately i think speaking about it is toxic because it gets you associated with “those anti vaxxers “.

About half the responses I’ve gotten in email have criticized me for supporting Joe Rogan (I don’t) and half for suggesting that any young person should ever be vaccinated against covid (I think it should be up to them, of course).

Yikes.

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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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Aug 15, 2023·edited Aug 15, 2023Author

My reading of it is that Pfizer vax caused myocarditis at about the same rate as covid in that series. That is, young men were about as likely to be hospitalized with myocarditis from Pfizer vaccine as from myocarditis from covid. Much more likely to be hospitalized after Moderna vax compared to covid. I edited the post to ensure no confusion.

Scandinavian study showed increased risk from Pfizer vax (appeared likely greater than covid risk, but less than Moderna risk) see link in post.

All that was from delta era.

After omicron, with lower risk of covid myocarditis (no hard data but appears very likely to be the case), and widespread immunity from prior infections making their risks from covid even less, young healthy men should have been , and should be made aware of the actual vaccine induced myocarditis risks vs benefits (esp for Moderna vax) not told the opposite, and in the generally lower risk omicron era, should be allowed to choose , not forced to be vaccinated in order to go to college or work. That’s the argument.

Thanks for commenting

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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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I felt helpless and was frequently in despair during those days. I gave a lot of convalescent plasma which probably didn’t help physiologically. I don’t know if it was right. medicine is not only about science. It’s not even mostly about science. Science just helps us do the things you were so passionately doing - caring, trying, giving of yourself to help another. Thank you for sharing this.

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Aug 7, 2023Liked by PulmCCM

Yep I feel you. Those were the feelings I had: helplessness and despair. But, giving convalescent plasma was better than doing nothing! At the time it was another "promising therapeutic", and, some patients did better with it.

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