Adolescent myocarditis cases after Pfizer/BioNtech vaccination appear mild

A couple of weeks ago, rumors were flying. In several hospitals around the United States, there were stories of multiple adolescents being hospitalized after receiving the Pfizer/BioNtech vaccine because they had developed a condition known as myocarditis. Myocarditis is a condition that causes inflammation to the tissue in the heart. It is commonly caused by a slew of viruses and most frequently occurs in young people. In fact, covid-19 itself has been proposed to cause myocarditis, though a compelling statistical link has not yet materialized.

Nevertheless, the question on everyone's mind was simple: could the cure, vaccines, somehow be worse than the disease, covid-19, for young people? The answer would ultimately depend on the rates of the complication—if indeed, myocarditis is being caused by the vaccines at all—and the severity of the outcomes.

A new case series out of Oregon Health Sciences University appearing in the influential journal Pediatrics provides important and ultimately reassuring data. The researchers described 7 cases of post-vaccine myocarditis. In each case, the affected adolescents improved rapidly. No serious outcomes were reported. All 7 cases were males, 6 White and one Latino. The age range was 14 to 19 years of age. All of the patients were previously healthy. Each of them developed chest pain and some other symptoms, including fever in 5 cases (two measured, three subjectively reported but not measured), and body aches, in others. A handful of other complaints were noted in individual cases. All of the patients had short-lived elevations in the cardiac troponin levels in their blood; cardiac troponin is a heart protein that can indicate stress or damage to the heart. The patients' electrocardiograms (ECGs) were a bit of a mixed bag, but some were consistent with what we usually see with myocarditis—which, it bears mentioning, is markedly different from the pattern and implication from a true heart attack, a different disease altogether. None of the patients required medications to help maintain their blood pressure, none required oxygen, and only one had any abnormal findings on echocardiography (an ultrasound which checks on the ability of the heart to pump blood efficiently; the findings were mild). 

The key here is to compare all this to the outcomes of pediatric hospitalizations for covid-19. A new study in the US Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report released last week found 204 adolescents ages 12-17 had been hospitalized for covid-19 among a cohort of people in 14 US states over a 3-month period this winter and early spring (note: there were actually 376 hospitalizations, but in 172 cases, covid-19 was deemed not to have been the clear-cut reason for the hospitalization). Of the 204 adolescents in this cohort hospitalized primarily for covid-19, nearly one in three required intensive care unit admission, and 5 percent required mechanical ventilation. Fortunately, no deaths occurred. However, the long-term effects of illnesses this severe are as-yet unknown.

There will no doubt be more rumors—some substantiated and some not—about side effects associated with the covid-19 vaccinations. Whenever that occurs, it will be important to use the right benchmark comparison. The question to ask will always be, what would have happened to a similar number of people if they had acquired covid-19 instead. So far, the outcomes among the vaccinated and those contracting covid-19 have not even been close. The vaccines are far safer than SARS-CoV-2, the infection that causes covid-19, for every age group. Avoiding covid-19 remains the highest priority.


Fighting to preserve telehealth in the post-pandemic era

Early on in the covid-19 pandemic, the US federal government embraced telehealth to an unprecedented degree, citing the difficulties, or impossibilities of otherwise seeing a healthcare provider. While there was an initial honeymoon period during which essentially care provided during any telehealth appointment was reimbursed at the same rate as in-person visits, many major healthcare insurers were quick to narrow the terms of this type of coverage. While there was a legislative push last session to make the increased reimbursement rates permanent, these efforts ultimately failed, and it has only been through targeted efforts that any portions of telehealth have had continued support.

The broad uptake of virtual appointments has demonstrated that many primary care and preventive medicine issues can be handled perfectly well remotely, with the only barrier to their continued use post-pandemic being insurer unwillingness to adequately fund their use. In a pushback to continuing to provide coverage, some insurers have begun to raise concerns of fraud and/or cost escalation. 

But the best answer for patients is not to undo what has proven a lifeline to many rural and underserved individuals. Rather, governments should establish regulations and guidelines to prevent and punish any would-be abuses. We can't let the potential for misuse or fraud by healthcare providers (or even a few bad apples who actually do engage in it) to stop vulnerable populations from continuing to access vital healthcare resources. For many people, getting to an appointment is an insurmountable challenge. Some, albeit not all, of these individuals can and do have internet access or the support of family and other important people in their lives who can aid them in attending telehealth visits. This innovation needs to remain an option, even after the covid-19 pandemic recedes. Various.

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