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University-age vaccine mandates: reply to Lam and Nichols
  1. Tracy Beth Høeg1,2,
  2. Allison Krug3,
  3. Stefan Baral4,
  4. Euzebiusz Jamrozik5,
  5. Salmaan Keshavjee6,
  6. Trudo Lemmens7,
  7. Vinay Prasad1,
  8. Martin A Makary8,
  9. Kevin Bardosh9,10
  1. 1 Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
  2. 2 Department of Clinical Research, University of Southern Denmark, Odense, Syddanmark, Denmark
  3. 3 Artemis Biomedical Communications LLC, Virginia Beach, Virginia, USA
  4. 4 Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  5. 5 Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
  6. 6 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  7. 7 Faculty of Law and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  8. 8 Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
  9. 9 School of Public Health, University of Washington, Seattle, Washington, USA
  10. 10 Division of Infection Medicine, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Tracy Beth Høeg; tracy.hoeg{at}

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We thank Leo Lam and Taylor Nichols for their response1 to our paper ‘COVID-19 vaccine boosters for young adults: a risk–benefit assessment and ethical analysis of mandate policies at universities’.2 In our paper, we demonstrate that the risk–benefit calculus to mandate boosters for young adults aged 18–29 is a net risk intervention. The authors assert that we have made three inappropriate comparisons of benefits versus risks of the mRNA vaccine booster dose in this age group. We provide our response to each below. We erred on the side of overestimating benefits of the booster dose against severe COVID-19 in this age group and still found net harms to outweigh net benefits. The conclusion of our paper holds, and university booster mandates for young people were—and remain—unethical.

COVID-19 hospitalisations prevented versus booster serious adverse events (SAEs)

For the first comparison, we weighed predicted hospitalisations prevented by one booster dose of BNT162b2 with vaccine-associated SAEs from the manufacturer’s randomised trial (3/5055).3 We found that the rate of expected SAEs would outweigh the benefits of the booster against hospitalisation by at least 18-fold. Lam and Nichols suggest that this was an inappropriate comparison, as not all SAEs result in hospitalisation. However, the definition of SAE as used in the trial included death, hospitalisation, disability, permanent damage, life-threatening event or condition, which required medical or surgical intervention to prevent a serious outcome.4 While all comparisons include some degree of incommensurability, comparing these SAEs with hospitalisations prevented by the booster is more reasonable than Lam and Nichols’ suggestion of comparing SAEs to infections prevented. The COVID-19 infection hospitalisation risk in this age group was <0.5% (or <1/200)5 even prior to widespread immunity, thus comparing SAEs to infection risk is entirely inappropriate. Furthermore, a booster dose will only offer transient (if any) protection against infection6 and cumulative infection rates …

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  • Twitter @tracybethhoeg, @KrugAlli

  • Contributors TBH drafted the manuscript. AK drafted some specific responses, each of the other authors contributed factual and ethical arguments and approved the final draft. SB and EJ reviewed and edited the manuscript to add ethical considerations to the framework. SK and TL reviewed and edited the legal aspects of the arguments. VP and MAM reviewed and edited the manuscript. KB reviewed and edited the manuscript to add the ethical analysis response.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

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