Meanwhile, HypoFlog and Tibs be saying we need to vaccinate all children.
Good to be right. Again.
The agency should revisit its latest guidance to maximize benefits and minimize risks
www.medpagetoday.com
Last week, the CDC's Advisory Committee on Immunization Practices (ACIP) met to discuss the safety signal of myocarditis among young people who receive mRNA vaccination against COVID-19. This dialogue has been months in the making. Ultimately, the panel continued to endorse a two-dose mRNA strategy for all ages. We are concerned with this recommendation and offer five alternative considerations. But first, let's review how we got to this moment in order to make sense of vaccine-induced myocarditis.
A Recent History of Vaccine-Induced Myocarditis
The potential risk for vaccine-induced myocarditis was first raised on February 1 in the
Jerusalem Post, which reported the hospitalization and intensive-care admission of a healthy 19-year old male 5 days after receiving his second dose of the Pfizer vaccine. This was followed by a nationwide report in the
Times of Israel on April 23, later picked up by
Reuters on April 25. These news reports suggested that Israel had seen elevated rates of this event after young men were vaccinated with the Pfizer vaccine, almost always after the second dose (56 out of 62 cases or 90%).
The European Medicines Agency
announced an investigation on May 7, which was the same day several of us
cautioned against FDA's use of emergency use authorization (EUA) to expedite the availability of COVID-19 vaccines to U.S. kids ages 12 to 15.
Although they were aware of this safety signal, the
FDA issued the EUA on May 10 for Pfizer's mRNA vaccine in kids ages 12 to 15. Despite the fact that the vaccine was already widely in use in people ages 16 and above under the existing EUA, specific rates of myocarditis in the U.S. for 'near age' vaccine recipients (kids ages 16 to 18) were not made publicly available. In other words, no data on myocarditis events in kids close in age to the group receiving the new EUA (those ages 12 to 15) were leveraged in the process for granting this EUA. This is unfortunate, as these data would have had the greatest relevance and implications for the adjacent-age group.
Over the last 2 months, several news reports on clusters of cases of myocarditis after mRNA vaccination -- particularly in
young men -- have
been reported in the U.S. Revised estimates from Israel found the rate of myocarditis to be to
one in 3,000 to one in 6,000 among males ages 16 to 24. On May 26, the
Times of Israel reported that Israel's health ministry would consider just one dose in teens to balance getting most of the benefit of viral protection against mitigating much of the risk of myocarditis.
Israel now recommends vaccinating kids 12 to 15, but other nations have been more cautious. The U.K. advisers have decided not to support vaccination for kids under 18. The Germany standing vaccination commission advised that only children with pre-existing conditions receive the vaccine. The Netherlands (Dutch) health counsel advised only kids with pre-existing conditions or those living in a household with a family member who cannot be vaccinated receive the vaccine.
On May 22, the
CDC announced they had received reports of myocarditis, and asked healthcare providers to file additional and missing reports into the Vaccine Adverse Event Reporting System (VAERS).
Last week, on June 23, ACIP met to discuss the findings. To date, CDC has
documented myocarditis in at least 323 cases age 29 or under (of whom 96% were hospitalized), while 148 remain under review. The CDC acknowledged more cases in young people than older people, more cases in young males than young females, and higher incidence after dose two than dose one. The absolute risk of myocarditis after the second dose based on the number of CDC confirmed cases would be one in 15,000 to 20,000 for boys ages 12 to 24. There is a smaller but still excess risk in women age 24 and younger.
At its meeting, ACIP considered figures and data, which claimed to weigh the benefits versus harms of "dose two" of mRNA vaccines in this age group. However, in reality, the scenarios presented by the CDC compared the risks versus benefits to young people of no vaccination at all versus a scenario in which they received both shots.
The CDC did not consider the harms versus benefits of one versus two doses, but only the harms versus benefits of vaccination itself. But the CDC went beyond this. They also used base rates of infection from the past, rather than current rates of SARS-CoV-2 spread, which are substantially lower. They did not differentiate between healthy kids -- who are at risk of idiosyncratic events, such as myocarditis -- and kids with pre-existing medical conditions that place them at high risk of severe outcomes from COVID-19, including hospitalization.
This insistence on an all-or-nothing, one-size-fits-all binary approach -- treating healthy kids who have recovered from confirmed prior infection as equivalent to infection-naive kids with comorbidities -- is at the heart of the fallacy underpinning ACIP's decision.
While we acknowledge the CDC and ACIP had to act based on short-term studies and limited and variable data, vaccines must be used in a way that maximizes benefit and minimizes risk.
Ultimately, the CDC's recommendations came out so unequivocally in favor of vaccination that the following is true: If a 15-year-old recovers from COVID-19 and has high antibody levels, and this 15-year-old then receives one dose of mRNA vaccine causing hospitalization from myocarditis, the CDC would still contemplate proceeding with dose two once the "heart has recovered."
These events raise several points of concern:
- VAERS is a suboptimal system. While the VAERS system was well-positioned to detect a rare and entirely unprecedented safety event (e.g., vaccine induced thrombocytopenia and thrombosis in the cerebral vessels), the system is suboptimal for elevations in naturally occurring health outcomes. Voluntary reporting requires a provider to make a mental link between vaccination and the outcome, and the mere fact that the CDC received more cases after coverage in the New York Times is evidence that VAERS failed to capture these events without prompting. This indicates cases may still be underreported: U.S. rates are likely a floor and not a ceiling. The meticulous tracking in Israel is likely closer to the real figure. Facing a factor-of-5 discrepancy between rates reported by Israel and the U.S., it is not prudent to simply assume that Israel is overcounting myocarditis, rather than the other way around.
- If you change even one assumption, the CDC's model tips. Using the CDC's own framework of risk and benefit, key differences tip the calculus. First, the comparison doesn't have to be either two doses or no doses. We can also consider just a single dose. Dose two is associated with greater rates of myocarditis, and one dose of an mRNA vaccine has strong protection (over 90% for severe outcomes) -- even against novel variants such as Delta. If you do this, the calculus tips. Second, building on this model, if one assumes rates of myocarditis documented in Israel, accepting the hypothesis that VAERS underestimates risk, it gets even worse. One of us (Wes Pegden, PhD) re-ran the CDC's analysis accounting for this, which shows that second dose vaccination is unfavorable at young ages. Finally, the CDC's analysis uses SARS-CoV-2 rates from the past -- when fewer adults were vaccinated. Rates might rise in the fall, but that's unclear.
