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COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities
  1. Kevin Bardosh1,2,
  2. Allison Krug3,
  3. Euzebiusz Jamrozik4,
  4. Trudo Lemmens5,
  5. Salmaan Keshavjee6,
  6. Vinay Prasad7,
  7. Marty A Makary8,
  8. Stefan Baral9,
  9. Tracy Beth Høeg10,11
  1. 1 School of Public Health, University of Washington, Seattle, Washington, USA
  2. 2 Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
  3. 3 Epidemiology, Artemis Biomedical Communications, Virginia Beach, Virginia, USA
  4. 4 University of Oxford Wellcome Centre for Ethics and Humanities, Oxford, UK
  5. 5 Faculty of Law and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  6. 6 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  7. 7 Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
  8. 8 Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
  9. 9 Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  10. 10 Clinical Research, Acumen, LLC, Burlingame, California, USA
  11. 11 Sierra Nevada Memorial Hospital, Grass Valley, California, USA
  1. Correspondence to Dr Euzebiusz Jamrozik, University of Oxford Wellcome Centre for Ethics and Humanities, Oxford, OX3 7LF, UK; euzebiusz.jamrozik{at}ethox.ox.ac.uk

Abstract

In 2022, students at North American universities with third-dose COVID-19 vaccine mandates risk disenrolment if unvaccinated. To assess the appropriateness of booster mandates in this age group, we combine empirical risk-benefit assessment and ethical analysis. To prevent one COVID-19 hospitalisation over a 6-month period, we estimate that 31 207–42 836 young adults aged 18–29 years must receive a third mRNA vaccine. Booster mandates in young adults are expected to cause a net harm: per COVID-19 hospitalisation prevented, we anticipate at least 18.5 serious adverse events from mRNA vaccines, including 1.5–4.6 booster-associated myopericarditis cases in males (typically requiring hospitalisation). We also anticipate 1430–4626 cases of grade ≥3 reactogenicity interfering with daily activities (although typically not requiring hospitalisation). University booster mandates are unethical because they: (1) are not based on an updated (Omicron era) stratified risk-benefit assessment for this age group; (2) may result in a net harm to healthy young adults; (3) are not proportionate: expected harms are not outweighed by public health benefits given modest and transient effectiveness of vaccines against transmission; (4) violate the reciprocity principle because serious vaccine-related harms are not reliably compensated due to gaps in vaccine injury schemes; and (5) may result in wider social harms. We consider counterarguments including efforts to increase safety on campus but find these are fraught with limitations and little scientific support. Finally, we discuss the policy relevance of our analysis for primary series COVID-19 vaccine mandates.

  • COVID-19
  • Epidemiology
  • Ethics- Medical
  • Civil Rights
  • Coercion

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The data are cited in table 1 and in the references. All data and calculations are included in the manuscript. We are providing the following citations as well: 18. Oliver S. Updates to the evidence to recommendation framework: Pfizer-BioNTech and Moderna COVID-19 vaccine booster doses. ACIP Meeting. 19 November 2021 (Slides 26, 29, 30, 31, 37). Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-19/06-COVID-Oliver-508.pdf. Accessed on 28 March 2022; 50. CDC. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE): Pfizer-BioNTech, Moderna, and Janssen COVID-19 booster doses. 29 October 2021. Available at: https://www.cdc.gov/vaccines/acip/recs/grade/covid-19-booster-doses.html%23table-03a; 51. Shimabukuro T. Update on myocarditis following mRNA COVID-19 vaccination. Advisory Committee on Immunization Practices (ACIP). 23 June 2022. Available at: Update on myocarditis following mRNA COVID-19 vaccination (cdc.gov). Slides 10 and 23. Accessed on 20 August 2022; 52. Shimabukuro T. Myocarditis following mRNA COVID-19 vaccination. Advisory Committee on Immunization Practices (ACIP). 19 July 2022. Available at: Myocarditis following mRNA COVID-19 vaccination (cdc.gov). Slides 11 and 23. Accessed on 20 August 2022; 53. Sharff KA, Dancoes DM, Longueil JL, et al. Myopericarditis after COVID-19 booster dose vaccination. Am J Card 2022;172:165–166. https://doi.org/10.1016/j.amjcard.2022.02.039; 54. Friedensohn L, Levin D, Fadlon-Derai M, et al. Myocarditis following a third BNT162b2 vaccination dose in military recruits in Israel. JAMA Apr 26;327(16):1611–1612. doi:10.1001/jama.2022.4425.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The data are cited in table 1 and in the references. All data and calculations are included in the manuscript. We are providing the following citations as well: 18. Oliver S. Updates to the evidence to recommendation framework: Pfizer-BioNTech and Moderna COVID-19 vaccine booster doses. ACIP Meeting. 19 November 2021 (Slides 26, 29, 30, 31, 37). Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-19/06-COVID-Oliver-508.pdf. Accessed on 28 March 2022; 50. CDC. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE): Pfizer-BioNTech, Moderna, and Janssen COVID-19 booster doses. 29 October 2021. Available at: https://www.cdc.gov/vaccines/acip/recs/grade/covid-19-booster-doses.html%23table-03a; 51. Shimabukuro T. Update on myocarditis following mRNA COVID-19 vaccination. Advisory Committee on Immunization Practices (ACIP). 23 June 2022. Available at: Update on myocarditis following mRNA COVID-19 vaccination (cdc.gov). Slides 10 and 23. Accessed on 20 August 2022; 52. Shimabukuro T. Myocarditis following mRNA COVID-19 vaccination. Advisory Committee on Immunization Practices (ACIP). 19 July 2022. Available at: Myocarditis following mRNA COVID-19 vaccination (cdc.gov). Slides 11 and 23. Accessed on 20 August 2022; 53. Sharff KA, Dancoes DM, Longueil JL, et al. Myopericarditis after COVID-19 booster dose vaccination. Am J Card 2022;172:165–166. https://doi.org/10.1016/j.amjcard.2022.02.039; 54. Friedensohn L, Levin D, Fadlon-Derai M, et al. Myocarditis following a third BNT162b2 vaccination dose in military recruits in Israel. JAMA Apr 26;327(16):1611–1612. doi:10.1001/jama.2022.4425.

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Footnotes

  • Twitter @KrugAlli

  • Contributors KB, AK and TBH led the team of bioethicists, epidemiologists, legal scholars and clinicians in conceptualising the analysis and manuscript. AK researched the inputs for the risk-benefit analysis, performed the computations, and created the visuals. AK, KB and TBH were responsible for the design of the figures and table. KB and EJ drafted the ethical analysis. Other authors contributed equally to the writing, review, editing and analysis of this manuscript.

  • Funding This study was funded by Wellcome Trust (216355, 221719, 203132).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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