• Transgender toddlers treated at Duke, UNC, and ECU

    Updated: July 7th, 2023

    Top medical schools in the state are now transitioning toddlers and training future primary care doctors on how to engage in the experimental treatment.

    Duke Medicine opened its Gender Clinic in 2015 to offer a wide variety of services under one roof. The clinic treats children as young as two for gender dysphoria.

    Dr. Deanna Adkins, a transgender activist who runs the clinic, said this about her toddler trans patients in an interview with the Charlotte Observer in 2016:

    “They are not old enough to consciously just choose to do that. … It is not a choice in any of my patients. It’s really an unpleasant thing to have going on in your body to feel that distress about yourself. I can’t imagine anyone who would choose to do that.”

    In her expert declaration to a federal district court in North Carolina concerning H.B. 2 Adkins stated, “From a medical perspective, the appropriate determinant of sex is gender identity.”

    Adkins argues that gender identity is not only the preferred basis for determining sex, but “the only medically supported determinant of sex.” Every other method is bad science, she claims:

    “It is counter to medical science to use chromosomes, hormones, internal reproductive organs, external genitalia, or secondary sex characteristics to override gender identity for purposes of classifying someone as male or female.”

    This ludicrous sentiment explains how this doctor can see a 2-year-old girl play with a toy truck, and then begin treatment for gender dysphoria.

    A few miles down the road, at UNC Health, children as young as three can be evaluated for gender dysphoria. The clinic states it practices “gender affirming care” (gender transitioning) on its intake form:

    UNC Gender Clinic Intake Form

    Interested parents are assured on UNC’s website that a team of psychiatrists, endocrinologists, family doctors, and surgeons will collaborate to “affirm” their child’s gender.

    How eager is UNC Health to “affirm” gender (i.e chemically sterilize and castrate)?

    So eager that its medical school residents offer cross sex hormones for free every third Wednesday.

    ECU Heath recently jumped on the bandwagon and opened it’s own “Pride Clinic” seeing children of all ages. The activist who directs the clinic, Dr. Colby Dendy said this in an interview with the East Carolinian:

    “The literature tells us that kids can start around age four having their gender identity, so we do not want to exclude anybody within the pediatrics realm,” Dendy said. “A big part of our goal is to provide affirming primary care to everybody in LGBTQ+ spectrum.”

    A majority of ECU Health family medicine doctors indicate they are trained and ready to accept an influx of patients on the center’s website.

    Dendy and her colleagues at ECU published a recent paper calling for doctors and clinics to push puberty blockers and hormones through telemedicine and school awareness programs.

    A month after the doctors at the ECU Pride Clinic published the paper, the school announced it received $3.2 M for a telepsychiatry program for school children.

    Do you believe in coincidences?


    All of these institutions offer intensive therapy sessions for children wishing to change genders with conversion therapy. But what about medication?

    In court testimony, Duke doctor Deanna Adkins explained how she treats youngsters:

    Before puberty, treatment does not include any drug or surgical intervention. For this group of patients, treatment is limited to “social transition,”which means allowing a transgender child to live and be socially recognized in accordance with their gender identity.

    This can include allowing children to wear clothing, to cut or grow their hair, to use names and pronouns, and to access restrooms and other sex-separated facilities and activities in line with their gender identity instead of the sex assigned to them at birth.

    Social transition is a critical part of treatment of patients with gender dysphoria of all ages and it is the only treatment for pre-pubertal children.

    A recent study published in Pediatrics examined the 5-year gender identity development trajectory of transgender-identified children who underwent early social gender transition. Five years later, at the average age of 11-12, almost all—97.5%—continued to identify as transgender, including a small subset (3.5%) developing a non-binary identification.

    Only 2.5% of the children desisted from transgender identification by the end of the study period, and re-identified with their sex.

    Another study conducted by the Left-wing American Academy of Pediatrics reports that once children socially transition at an early age, they will generally remain transgender at five-year followup. This means the four-year-old who has brainwashed to believe he was born in the “wrong body” will remain confused, and depressed, at aged nine.

    These doctors and clinics know that by catching children and their families at two or three, they can generate enormous amounts of cash because patients will likely rely on a lifetime of medication.

    Legislation to ban this practice now sits in the North Carolina House and Senate. Please call your representative, email them this report, and urge them to pass the Youth Protection Act immediately.


    Optimize your FLFE experience by consciously participating in the process.


    You may use this checklist to do a self-check in.

    1. Are you sufficiently and consistently hydrated?
    2. Are you supplementing daily with Magnesium and Essential Fatty Acids (fish or flax oil)?
    3. Are you getting sufficient sleep?
    4. Are you getting plenty of sunshine or supplementing Vitamin D, daily?
    5. Are you using any techniques to process and release emotional patterns? (EFT, Emotion Code, Meditation, Acupuncture, etc.)
    6. Do you have a spiritual practice, and are you keeping up with it?
    7. Have you turned the service ON/OFF, used your boost, or adjusted the slider on your control panel to feel a difference?
    8. Are you consciously choosing positive thoughts and attitudes? Are you expecting solutions?

    Tuning Into the FLFE Service

    Everyone reacts to FLFE a bit differently, yet we’ve seen a common thread of experience and benefits that runs through most of our customer feedback. These questions are based on feedback from people experiencing FLFE.

    As you read through the following questions, feel free to pause and consciously “tune into” that perception.

    1. Are you feeling a greater sense of well being and feeling more relaxed?
    2. Do you feel a relaxing of tension and it feels easier to breathe, particularly when you turn off and then back on the EMF Mitigation program?
    3. Do you have more clarity and concentration?
    4. Do you feel more creative? As though things are flowing more?
    5. Are you sleeping better?
    6. Have you noticed your thinking is clearer and sharper?
    7. Do you feel more balanced emotionally?
    8. Are you more patient with yourself and others?
    9. Do you feel the need to clean your space and declutter?
    10. Have you received that new job offer you were waiting for?
    11. Has money come in that you’ve been waiting for?
    12. Are your pets happier?
    13. Do you find it easier to get up in the morning? Or suddenly your kids are getting up and getting themselves ready for school in the morning with less or no struggle?
    14. Have you found your kids have started cleaning at home without being told to do it?
    15. Do your neighbors, friends or family members comment how good your home feels and seem to want to stay?
    16. Do you feel you want to stay at home more?
    17. Is your relationship more loving?
    18. Has the communication between the people sharing the space improved or between you and your spouse improved?
    19. Has the communication with your coworkers and others in your family improved?
    20. Is your neighborhood changing around you? Have you noticed better relationships or even new or happier neighbors?
    21. Does the maintenance of your property seem to be easier?
    22. Are you feeling more productive at work?
    23. Does making key decisions appear to be easier?
    24. Are you clearing old negative patterns and or old insecurities quickly?
    25. Are you feeling you are reaching higher states when meditating?

    Ways You Might Discern the Presence of the FLFE Field

    The FLFE field is a subtle energy phenomenon. It is focused life-force energy, which is the same type of energy that is recognized by Chinese medicine as the energy that runs through the meridians in our bodies, also known as chi, prana, qi, or life-force. Modern science has acknowledged that acupuncture in Chinese medicine is a valid healing modality.

    You have a sensitivity to this energy naturally somewhere on a spectrum from highly sensitive to mildly sensitive. As a result of peoples’ innate ability to sense and to adapt to new environments (basic survival instinct) we believe that your ability to sense, work with and evolve with the FLFE environment will increase over time. If you are on the upper end of the sensitivity scale, you may have felt the moment the FLFE energy was engaged with your home or mobile phone. During our Beta testing, we had a friend in another city who could feel the energy. At his home we turned the FLFE field on and off dozens of times and he could accurately tell us when it was on and when it was off.

    If you would like to develop your discernment for the FLFE field and for subtle energy intensity (we measure as level of consciousness) in other locations, here are some suggestions.

    Contrast. What do you feel when leave and come back to the property? Or go away from your phone? You could also try sitting quietly and using your FLFE Customer Portal to turn the service and/or the EMF Mitigation program on and off.

    Explore where in your physical body you notice a sensation that might indicate an activation of the body due to the FLFE energy (high level of consciousness present).

    1. Some individuals feel it in their pineal gland (between the eyes and a little higher).
    2. Some individuals feel it in their heart, a feeling of expansion and perhaps joy.
    3. Some individuals feel a tingling sensation in their nervous system throughout their body or in a particular part of their body. Those who are experienced in sensing the chakra system in their body through such practices as yoga may notice an increased movement or warmth or another expression of increased activation.
    4. Some individuals feel an overall increase in energy flow throughout the body.
    5. Some individuals feel an activation of the crown chakra, which can feel like pressure or energy flow through the top of the head.

    Please note: If you have a home subscription, the FLFE energy is associated with your entire property, which includes your yard, if you have one. In that case, it is helpful to walk off your property and up the street and then return to feel the difference. If you live in an apartment or condo, please note that the FLFE energy and the subsequent rise in the level of consciousness radiates from your home and raises the energy in the hallways and adjoining units. If you are doing this experiment, it is helpful to walk further away from your apartment or condo, perhaps out onto the sidewalk and then return.

    With mobile, the radius is 300 feet – though some programs, such as those positively impacting your health – only work when your phone is within four feet.(-a reminder, your phone does not need to be on to create the FLFE field).

    You might also experiment with turning FLFE on and off (using your Control Panel) while sitting quietly with your eyes closed.

    Observation. How do others react? In order to observe the feeling and result of the FLFE wave entanglement and the subsequent rise in the level of consciousness without the placebo effect, observe others who are unaware of the FLFE wave.

    1. Observe how others react. Particularly when people enter for the first time after you have added the FLFE wave. We and our customers have observed people exclaiming how good it feels or asking what we have done to redecorate, paint, new furniture when these things haven’t been done.
    2. Observe how people will tend to stay longer in your FLFE environment. You might need to have more groceries on hand!
    3. Get feedback. Ask others if they notice a difference in the way they feel when in your space.
    4. Harmony in relationships and/or visitors. One user remarked at how people from a business group came over and were exceedingly joyful and open, far more than they would have normally been.
    5. One person with a mobile subscription observed how a highly negative person literally avoided her in the hallway; it was incredible, by her own description.
    6. Turn the FLFE service on and off using your Control Panel and see if they can tell the difference. This is interesting to do in a group, as people have different levels of sensitivity.

    Reflection. Being called to upgrade your environment to reflect the higher energy state.

    1. You may feel inspired to declutter or rearrange the furniture in your home as a natural sense of order and energy movement occurs.
    2. You may notice in yourself and others an impulse to clean, redecorate or improve the home in some way to match the higher energy state.
    3. If you have a yard you may notice an impulse to garden, beautify or otherwise tend more to your outside environment.
    4. You may notice your neighbors upgrading or cleaning their property as well.

    Niacin Detox Sauna Therapy

    The Niacin detox program is my favorite detox method.  Not only is it extremely simple and extremely cost effective, it’s also one of the most powerful detox protocols out there.

    How powerful you ask?

    Ok, let’s just say that, this is the SAME detox program that the 911 firefighters were put on to professionally and successfully treat their extreme overexposure of toxic dust (a wide array of poisons, including lead, polycyclic aromatic hydrocarbons, polychlorinated biphenyls, dioxins) from the WTC buildings collapsing.

    iacin Detox Program - 911 fire fighter with his purple manganese towel

    Severe Example:  One of the firefighters who had an extreme case of toxicity developed severe Parkinson-like tremors with many other serious cognitive problems.  He was treated with a Niacin Detox program with a high dose of Niacin (Slowly built to 5000 mg for 30 days).

    After his detox, his sweat left a purple – blue residue on his towel. This residue was Manganese (Not magnesium) which is a type of metal known to onset tremors and cognitive issues.  After his detox, he was clear of his symptoms.

    Also, this is the same detox method used to professionally treat veterans with Gulf War Syndrome or Golf War Illness (GWI) . Look up Gulf War Syndrome Project headed by David Carpenter.

    Table of Contents [show]

    First Off, Why Should You Detox?

    We are CONSTANTLY exposed to toxins and heavy metals from our environment and the food that we consume.  Toxins are stored in our fat and brain tissue which directly impacts us physically and mentally. While eating healthy can help detox your body, it isn’t extremely effective.  Dr. George C. Yu, MD recommends that a Niacin detox program become part of our weekly regimen in order to stay healthy and remove harmful toxins that attribute to illnesses.

    Based on the Biosphere 2 Studies, Dr. Yu said,  “We also noticed that for the average person now, they are doomed to having lots of chemicals inside their bodies, from 500 times up [compared to their blood level results]” – this means that when you get a toxicity test done on your blood, it might show that you’re fine but in reality the toxins in your fat  will show that you are 500 times more toxic!

    My Results

    After my first session, I felt great, refreshed, and rejuvenated. It makes me excited for the next detox session every time – maybe I’ll get addicted! After doing this for a month (2-3 times a week), I noticed some big improvements after three sessions I completed. I noticed that my skin looks tighter and brighter, acne flare ups went away. Another big improvement is the overall feel the day after the detox.

    I’m a pretty stressed person, and I did not feel any stress throughout the day.  There is also a great increase of clarity and a “happy go lucky” type attitude.  When I thought about doing something, there was not a thought about the fears associated with that – for example “what if I see someone I don’t want to run into?”  I also play basketball in the mornings with a group of guys and I noticed that I didn’t care what people might be thinking of me and this allowed me to play with more confidence.  It was a weird feeling, good obviously.

    How Does it Work? What’s the Science Behind it?

    Niacin is Vitamin B3 and is created naturally in your body.  The premise behind the Niacin Detox is to take a high dose of Niacin paired with moderate to heavy exercise.  This combination mobilizes and stimulates lipolysis (break down of fats).  When you take Niacin, it induces a flushing effect that feels and looks like a sunburn.  Reaction time is different for each person but normally experienced in 5-10 minutes.

    As the fats break down, the toxins stored inside the fat are released to your blood stream and then you can remove it.

    If you don’t remove it, you reabsorb the toxins back into your body.

    There are two main ways to eliminate it from your body:

    1. Sweat – Sweating the toxins through the skin via exercise and sauna
    2. G.I. Tract – Excreting them out the G.I. tract by binding them with one of the following:
      • Activated Charcoal
      • Zeolite Clay
      • Oils
      • Even some fibers

    Dr. Yu and Dr. Mercola Explain a Little More


    What Toxins are Removed?

    1. Heavy Metals: Mercury, Manganese, Lead, Aluminum etc
    2. Pharmaceutical Drugs: Pain Killers, Prozac, etc
    3. Other Drugs: LSD, heroin, marijuana, PCP, cocaine, alcohol
    4. Formaldehyde, chlorines, Harmful PCBs
    5. Food Preservatives
    6. Pesticides & Herbicides
    7. Anesthetics
    8. and a lot of others

    Is the Niacin Detox Safe?

    Niacin is something that you already create in your body.  It is converted from your amino acids, tryptophan.  When detoxing, most people use niacin above its RDA value and don’t experience any problems other than the flushing effect.  Since you build up a tolerance to niacin, most people can start at 100 mg and slowly build up to taking 1000 – 1500 mg per session.  I personally don’t go above 2000 mg.  You can slowly build a tolerance by increasing the niacin dosage by 100 mg per detox session.  For some extreme conditions of toxicity like the 911 firefighters, you can reach up to 5000 mg per detox session – however you should still consult your doctor on this.

    The only caveat here, is if you take too much niacin too quickly, you will throw up.  Some people talk about liver toxicity which is only attributed to niacinamide – sources below.

    Is activated charcoal safe? In an interview from Dr. Yu and Mercola, activated charcoal is extremely safe and effective in pulling and removing toxins from your G.I. tract.  In fact, you can’t overdose on it.

    Below are PubMed articles supporting the health and detoxing benefits of saunas:

    What You Need & Brands I Recommend:

    1. Niacin: This is important. Make sure you get the flushing form of Niacin. Do not get niacin that has niacinamide as its active ingredient. This won’t make you flush and it’s shown to be toxic to your liver.  Start out with the 100 mg tablets. I use this Niacin – it has great flushing effects.  You can move to the 500 mg later.
    2. Activated Charcoal: Any type of active charcoal will work, however, I use this brand if you’re interested in exactly what I took.
    3. Purified Water: You’re doing a detox, make sure you’re drinking plenty of purified water. I use a water purifier since plastic water bottles have harmful BPA and BPS in them.  If you have fluoridated water, you’ll want a good filter to get this out. Regular Carbon filters like Pur or Brita won’t cut it.
    4. Purified water with a ½ teaspoon of Himalayan Salt. While in the sauna, you’ll want to replenish electrolytes (Himalayan Salt – 1 TBSP) and water (32 Oz).  Coconut water is a great source of electrolytes and also recommend it if you want to spend the money on it.  It’s fairly inexpensive.
    5. A good multi-vitamin: You’ll be flushing and sweating many things out, it’s important to get a good multi-vitamin or eat a diet with high nutrition. I really like this brand.
    6. Access to a Sauna: Your local fitness club will most likely have one.  Also try day spas, though these will more likely be more expensive.  Infrared Saunas are great too because they make you sweat faster.

    A Brief Overview of the Program:

    Purpose: A simple and extremely powerful detox method used by doctors to eliminate toxins.

    Consult your doctor:  With any diet, exercise, or supplement change, you should consult your doctor first before attempting to make sure this is right for you.  Everyone is different.

    Brief Overview:  Start with 50-100 mg of Niacin on empty stomach, start exercising for 30 min, enter sauna for 30-60 min, take 4-5  capsules of activated charcoal (500 mg), take shower.

    For your convenience, get my printable Niacin Detox Program PDF.  It’s condensed on 1 page, extremely helpful, and easy to take with you anywhere on your detox.Download the Easy PDF

    Duration: 2 times a week.

    Tips to increase a Niacin flush response:

    1. Crush Niacin into powder
    2. Take with hot or warm water
    3. Take on empty stomach

    Niacin Detox Program (Detailed):

    1. Take Niacin (Flushing Version):
      1. Take small dose of 50 mg with 4-8oz of water on empty stomach– This is to see how you react. Everyone is different. I didn’t flush my first time at 50mg and the next time I executed the program, I took 200mg and certainly flushed.
      2. Monitor Your Flush – It’s important to flush. Within 5-10 min you should feel a flushing effect starting in your face that moves down to your chest.  This feels and looks like a sunburn. If you don’t feel anything, this means that you’ll need to take more niacin next time you execute the program.  I find that I can help kick start the flush with some push ups and moderate jogging for a couple minutes of warmup.
        • Please Note: You might experience Your Flush Later when you’re in the Sauna
        • If you still do not flush – More than likely, your brand is the slow release niacin or Niacinamide or you had a meal with your niacin.
      3. Next time Increase the Dose – You build a tolerance to Niacin. Every time you execute the program Increase the dose by 100mg to 200mg depending if you feel a flush effect from the niacin or not. You can max out at 1000 to 1500 mg.
      4. If you took 300mg of niacin your first time, you would be fine, but it would be really uncomfortable for an hour – extremely tight skin, your skin feels itchy EVERYWHERE. It’s not the end of the world but it’s annoying.
      5. Wait 10 minutes after taking the Niacin to begin Step 2
    2. Exercise for 20 – 30 min: The goal here is to get your body in motion as much as you can and to exercise so that you’re building a sweat. Most people go with a moderate jog, however,  I find that any form of High Intensity Interval Training (HIIT) gives me the best results.  I usually go with simple wind sprints, push-ups and lifting weights.
      1. Caveat: This is what I do, which doesn’t mean you should do this. This is also dependent on your level of health and age. If you’re overweight or older, try jogging and some simple, lighter weights. As long as you’re moving, and sweating, you’re good.
      2. My Exercise Routine
        • Wind Sprints – 50 Yards sprint as hard and safe as you can. Right after you’re done sprinting, perform 10-15 push-ups. Rest 30 seconds.  I repeat this combo for about 5-7  times.  Obviously this won’t add up to 30 min so I finish it off with lifting weights – 1 to 2 sets of 10 reps trying to hit major muscle groups using 10-15 seconds rest in between.
      3. Sauna for 30 – 60 min (traditional):
        1. The goal is to get a good sweat going, eliminating as many toxins through the skin. I bring a towel to wipe the sweat off to encourage production of more sweat. I also use a card to scrape the sweat off the skin.
        2. Drink plenty of fluids inside the sauna. I drink a mixture of Himalayan salt water for electrolytes.
        3. Some people stay inside a traditional sauna for up to 4.5 hours. You can use an infrared sauna which you can achieve the same results for 4.5 hours in only 1 hour!
        4. Make sure that it’s hot when you enter. You should be sweating 5-10 min in.
        5. If you’re light headed from HIIT, avoid the sauna for a bit or closely monitor yourself. Elevated heat can cause you to faint if you’re already dizzy.
      4. Take Activated Charcoal: Take 2-4 capsules (500 mg) with 2-4 glasses ( 8 oz) of purified water.
      5. Shower: Rinse off sweat to prevent your skin from reabsorbing the toxins.  For the best effects, Dr. Yu recommends a cold shower.
      6. Vitamins: This amount of sweating depletes a lot of minerals and vitamins. Make sure that you take a multivitamin or have a high quality diet consisting of high nutritional value and vitamins.

    Further Reading, Studies, Support Resources, and Niacin Information

    Professionally administered Detox Programs:

    Self-Aided Detox Support Group:

  • COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities

    1. Kevin Bardosh1,2
    2. http://orcid.org/0000-0002-8912-264XAllison Krug3
    3. Euzebiusz Jamrozik4
    4. Trudo Lemmens5
    5. Salmaan Keshavjee6
    6. Vinay Prasad7
    7. Marty A Makary8
    8. http://orcid.org/0000-0002-5482-2419Stefan Baral9
    9. http://orcid.org/0000-0002-2341-6573Tracy Beth Høeg10,11
    10. Correspondence to Dr Euzebiusz Jamrozik, University of Oxford Wellcome Centre for Ethics and Humanities, Oxford, OX3 7LF, UK; euzebiusz.jamrozik@ethox.ox.ac.uk


    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.

    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.html23table03a; 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.


    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.


    Statistics from Altmetric.com

    See more details

    Picked up by 12 news outlets

    Blogged by 2

    Tweeted by 23044

    On 4 Facebook pages

    Referenced in 1 Wikipedia pages

    Reddited by 14

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Request permissions


    COVID-19 vaccine booster mandates have been controversial, especially in younger age groups. Two main factors continue to drive scientific controversy: a lack of evidence that booster doses provide a meaningful reduction in hospitalisation risk among healthy adolescents and young adults, and mounting evidence that widespread prior infection confers significant protection against hospitalisation due to (re)infection. Further, mandates have deleterious societal consequences and are eroding trust in scientific and government institutions.1 In North America, as of May 2022 at least 1000 colleges and university campuses required COVID-19 vaccination, and over 300 required boosters.2 More than 50 petitions have been written opposing these vaccine mandates,3 raising specific legal and ethical complaints.4 To our knowledge, few have changed their vaccine guidance for the 2022–2023 academic year and several have mandated the new bivalent booster.

    Policymakers, public health scholars and bioethicists have argued both for and against COVID-19 vaccine mandates. The strongest argument made by proponents of vaccine mandates is based on the harm principle: insofar as vaccines prevent transmission and thereby reduce harm to others, restrictions on individual freedom are viewed as more ethically justifiable.5 However, a reduction in risk to others (especially if this is a small or temporary effect) might not alone be sufficient to justify a booster mandate in young people. Savulescu6 and Giubilini and colleagues7 have argued that, to be ethical, vaccine mandates require four conditions: that the disease be a grave public health threat; that there is a safe and effective vaccine; that mandatory vaccination has a superior cost/benefit profile in comparison to other alternatives; and that the level of coercion is proportionate.

    Proportionality is a key principle in public health ethics.1 To be proportionate, a policy must be expected to produce public health benefits that outweigh relevant harms, including harms related to coercion, undue pressure, loss of employment and education and other forms of liberty restriction. Williams8 has argued that COVID-19 vaccine mandates may be justified for older but not younger people, among whom such policies are not proportionate given a lack of clarity that benefits outweigh harms. Such ethical assessments should rely on empirical data: thorough risk-benefit assessment requires quantification (where possible) of relevant risks and benefits for the group affected by the policy. With respect to poor outcomes due to COVID-19, the most consistent predictors are age9 and comorbidities.10 Similarly, age and sex are prominent risk factors for vaccine-associated reactogenicity11 and serious adverse events (SAE) such as myocarditis, which is more common in young males.12 Vaccine requirements should therefore be predicated on an age-stratified and sex-stratified risk-benefit analysis and consider the protective effects of prior infection.13

    In this paper, we integrate a risk-benefit assessment of SARS-CoV-2 boosters for adults under 30 years old with an ethical analysis of mandates at universities. Our estimate suggests an expected net harm from boosters in this young adult age group, whereby the negative outcomes of all SAEs and hospitalisations may on average outweigh the expected benefits in terms of COVID-19 hospitalisations averted. We also examine the specific harms to males from myo/pericarditis. We then outline a five-part ethical argument empirically assessing booster mandates for young people informed by the quantitative assessment. First, we argue that there has been a lack of transparent risk-benefit assessment; second, that vaccine mandates may result in a net expected harm to individual young adults; third, that vaccine mandates are not proportionate; fourth, that US mandates violate the reciprocity principle because of current gaps in vaccine injury compensation schemes; fifth, that mandates are even less proportionate than the foregoing analyses suggest because current high levels of coercion or pressure may create wider societal harms. We consider possible counterarguments including potential rationales for mandates based on a desire for social cohesion or safety and summarise why such arguments cannot justify current COVID-19 vaccine mandates. We suggest that general mandates for young people ignore key data, entail wider social harms and/or abuses of power and are arguably undermining rather than contributing to social trust and solidarity.


    To provide background for our risk-benefit assessment and ethical arguments, we outline recent controversies among experts regarding vaccine boosters and summarise current data on COVID-19 vaccines, specifically: vaccine effectiveness against transmission, effectiveness in those with prior infection and the age-stratified risk of severe COVID-19.

    Controversy among experts

    Most countries outside of North America have not required or mandated booster doses for young healthy adults at universities,14 suggesting that, at a minimum, there is a diversity of expert views on whether the expected benefits of such policies outweigh their potential harms. In July 2021, the Centers for Disease Control and Prevention (CDC) released a joint statement with the Food and Drug Administration (FDA)15 reassuring the public that boosters were not necessary. Just 2 months later, in September 2021, a US FDA advisory committee overwhelmingly voted 16-2 against boosting healthy young adults.16 Yet, this recommendation was over-ruled by the White House and CDC leading to the resignation of two high-level FDA vaccine experts. These experts wrote in The Lancet about the ‘…need to identify specific circumstances in which the direct and indirect benefits of doing so are, on balance, clearly beneficial’.17 To date, the only risk-benefit assessment made public has narrowly focused on myo/pericarditis in the absence of sufficient safety data from an appropriately powered trial.18 In fact, the CDC’s own evidence-to-risk framework found no COVID-19 hospitalisation in either booster (three-dose) or placebo (two-dose) groups of the BNT162b2 booster trial.19

    Because the mRNA vaccine third-dose booster trials were too small to measure important clinical endpoints, additional doses have been granted Emergency Use Authorization (EUA) based on observational data suggesting benefits in older populations.19 Prior to the emergence of the Omicron variant, the US CDC estimated19 that administering a booster dose to 8738 (BNT162b2) or 11 994 (mRNA-1273) 18–29 year-olds would prevent one COVID-19 hospitalisation over 6 months. As of August 2022, this estimate had not been updated to reflect increasing natural immunity or waning vaccine effectiveness. Data on booster vaccine effectiveness specific to young adults are scarce; reports typically either do not provide stratified data below a certain age (eg, 50 years20) or use younger adults as the baseline to assess effectiveness in older adults (in part because severe disease is already extremely rare in non-boosted young adults).21 In a recent CDC publication, which stratified for ages 18–49, a booster dose increased effectiveness against emergency department encounters and hospitalisations among immunocompetent adults during the Omicron wave, but the analysis did not adjust for comorbidities and excluded those with a history of prior infection ‘to reduce the influence of protection from previous infection’.22

    Risk-benefit calculations for the primary series among younger children and adolescents are similarly limited. A cohort study conducted in Hong Kong estimated the number needed to harm (NNH) from myo/pericarditis for dose 2 of BNT162b2 was 2563 among adolescent males,23 yet there was no US-specific NNH published by the CDC, nor did the agency recommend shifting to a one-dose policy for adolescents as did the UK, Norway, Taiwan and Hong Kong.23 The CDC first presented a risk-benefit analysis of booster vaccination in September 2021, yet the harms focused strictly on myocarditis versus all SAEs and collapsed age strata with very disparate myocarditis risks.24 Moreover, the CDC’s outdated risk-benefit analysis for adolescents and young adults does not distinguish important subgroups such as or those who have recovered from previous infection or healthy young people (as opposed to those with comorbidities or immunocompromised status).24

    Current data regarding COVID-19 vaccines

    A thorough ethical evaluation of risks and benefits requires relevant empirical data, especially where risks and benefits can be quantified to a reasonable degree of certainty. Relevant data include those regarding average individual vaccine safety and effectiveness and age stratification of these data as well as the protective effect of prior infection and the effectiveness of vaccines against transmission.

    Proponents of mandates have argued that current vaccines prevent transmission, which would support a standard ethical reason in favour of mandates: the protection of others. Yet it is increasingly clear that current vaccines provide, at most, partial and transient protection against infection, which decreases precipitously after a few months,25 26 with limited effects on secondary transmission.27 28 The CDC states: ‘anyone with Omicron infection, regardless of vaccination status or whether or not they have symptoms, can spread the virus to others.’29 It is therefore inaccurate in 2022 to infer a sustained or long-term reduction in transmission from a short-term reduction in infection.30

    A second limitation is ignoring the protective effects of prior infection. In February 2022, the CDC estimated that 63.7% of adults aged 18–49 years had infection-induced SARS-CoV-2 antibodies, up from 30% in September 2021.13 By September 2022, the majority of young adults, both vaccinated and unvaccinated, are estimated to have been previously infected with COVID-19. Evidence increasingly shows that prior SARS-CoV-2 infection provides at least similar (and perhaps more durable) clinical protection to current vaccines,31–33 which current university policies fail to acknowledge (in addition to more general uncertainties about risks and benefits in relevant age groups34).

    Mass vaccination had been proposed as a way to ‘end the pandemic’.35 However, elimination or eradication of the virus is not a tenable goal with vaccines that provide only temporary and incomplete reduction in infection risk, and the presence of multiple animal reservoirs. Because of this, nearly all human beings will eventually be infected with SARS-CoV-2, as with other endemic coronaviruses (and every pandemic influenza virus on record), many times in their life.36 Denmark has, for example, acknowledged vaccinating children was not effective at curbing spread of the virus and is no longer recommending vaccination against COVID-19 for most children.37 38 Taking population immunity into account with variant severity and projected coincident surges of influenza, SARS-CoV-2 and respiratory syncytial virus in the winter of 2022–2023, the UK’s Joint Committee on Vaccination and Immunisation (JCVI) currently recommends that high-risk groups be offered a booster.39

    A fourth point relates to the burden of COVID-19 in young adults under 40. Using pre-COVID-19-vaccinera mortality data from 190 countries, the adjusted infection fatality ratio for 18–29 year-olds ranged from 100 per million (18 year-olds) to 500 per million (29 year-olds) with significant variation by country within each age stratum.40 A recent study from South Africa during the Omicron BA.1–BA.4/5 wave demonstrates that despite a high proportion of breakthrough infections, the risk of hospitalisation remains lowest among young adults.41

    While both vaccination and prior infection can substantially reduce the likelihood of COVID-19 mortality,32 33 39 the protection against hospitalisation afforded by a booster wanes rapidly.41 The study from South Africa demonstrated that protection waned to less than 50% after 3–4 months.41 Protection against symptomatic disease can be initially restored but wanes approximately 10 weeks after a booster dose42; in the study from England, protection against severe disease could not be measured with the test-negative case–control design due to the few cases of severe disease during Omicron.42 Using a national population-wide data set in Qatar, both previous infection alone and vaccination alone were found to provide >70% protection against severe Omicron (BA.1 or BA.2) disease.43 However, the stratified data in Altarawneh, et al. supplemental table S5 show that prior infection alone was 91% effective against severe Omicron disease, whereas protection from two or three doses of vaccine alone was 66% and 83%, respectively.43

    Finally, COVID-19 does cause acute illness, and may have long-term effects (Long COVID) for some, particularly those who develop critical illness, but vaccination may not entirely prevent longer term sequelae44 and the existing data are non-randomised, from variants that predate Omicron and with unclear relevance for adults under age 40. The existence of effective treatments for clinical management45 is also an argument against vaccine mandates, especially for groups not considered at risk for severe illness.

    Risk-benefit assessment

    In a recent editorial, vaccine developer and paediatrician Paul Offit34 argued: ‘because boosters are not risk-free, we need to clarify which groups most benefit.’1 Below, we provide an Omicron-specific risk-benefit assessment of booster vaccination for young adults aged 18–29 years for both Pfizer (BNT162b2) and Moderna (mRNA-1273) vaccines. This analysis builds on a stratified risk-benefit analysis of vaccination among adolescents aged 12–17 years.46 For the booster among young adults aged 18–29 years, the calculations use the CDC’s pre-Omicron number needed to vaccinate (NNV),19 the estimated reduction in severity of Omicron versus Delta47 and current estimated seroprevalence.13 While harms from COVID-19 vaccines are uncommon,48 they should be factored into policy recommendations. This risk-benefit analysis considers the overall rate of reported SAEs (figure 1A) and grade ≥3 reactogenicity (figure 1B) and myo/pericarditis among males (figure 1C). Rates and definitions are consolidated in table 1A,B,C.

    Figure 1

    Figure 1

    (A, B, C) Expected hospitalisations prevented over six months and serious adverse events (SAEs), cases of grade ≥3 reactogenicity, and vaccine-associated myo/pericarditis among 18–29-year-olds per million BNT162b2 and mRNA-1273 booster vaccinations. *CDC-estimated number needed to vaccinate (NNV) with a booster to prevent 1 hospitalisation over 6 months in 18–29-year-olds18 was adjusted for reduced Omicron severity (aOR=0.28)47 as follows: BNT162b2 (8738/0.28=31 207) and mRNA-1273 (11 994/0.28=42 836). Per million third doses, hospitalisations prevented for BNT162b2 were computed as follows: 1/(8738/0.28)×106=1/31 207×106=32.0 and 1/(11 994/0.28)×106=1/42 836×106=23.3 for mRNA-1273 **SAEs: Three serious adverse events among BNT162b2 booster recipients were deemed by blinded investigators to be related to vaccination (3/5055). These included: moderate persistent tachycardia, moderate transient elevated hepatic enzymes, and mild elevated hepatic enzymes.18 50 †Reactogenicity rates are BNT162b2 (14/306) and 45 751.6 per million third doses; mRNA-1273 (18/167) and 107 784.4 per million third doses.50 ‡Estimated reactogenicity rates were computed assuming 63.7% seroprevalence13 and at least 2x reactogenicity among those with prior SARS-CoV-2 infection.56 57

    Table 1

    Risk-benefit analysis of third mRNA vaccination: definitions and rates for serious adverse events (SAEs), grade ≥3 reactogenicity and myo/pericarditis in 18–29 year-olds by manufacturer

    SAEs49 include those that: result in death or are life threatening; result in hospitalisation, prolongation of hospitalisation or significant disability/incapacity; cause a congenital anomaly/birth defect; or cause other medically important events.2 Grade 3 or 4 reactogenicity is defined as local/systemic events that prevent daily routine activities or require use of a pain reliever (grade 3) or resulting in an emergency room visit or hospitalisation (grade 4).49 50

    To estimate the expected harms (SAEs including myo/pericarditis and grade ≥3 reactogenicity) and benefits (COVID-19 hospitalisations prevented) specific to boosting young adults aged 18–29 years, we used data reported by CDC from phase II/III clinical trials,19 50–52 peer-reviewed observational data from large integrated health systems53–57 and postmarketing surveillance collected via V-Safe by the CDC.58 We compute harms and benefits per single hospitalisation averted as well as per million third doses administered.

    Hospitalisations prevented

    To estimate the benefits of hospitalisations prevented by boosters, we updated the CDC’s estimated NNV19 for Omicron, which was found to be markedly less virulent than Delta.47 We selected Trobajo-Sanmartín et al because the analysis provides stepwise comparisons of Omicron BA.1 to Delta (adjusted OR (aOR)=0.28, 95% CI 0.16 to 0.47), as well as the more recent BA.2 to BA.1 (aOR=0.52, 95% CI 0.29 to 0.95). To be conservative, we used the BA.1 versus Delta aOR rather than attempting to estimate the combined BA.2 versus Delta risk reduction. Scaling the CDC’s NNV estimates of 8738 for BNT162b2 and 11 994 for mRNA-1273 by this reduced severity, we estimate that 31 207 (8738/0.28) to 42 836 (11 994/0.28) young adults would need to be boosted with BNT162b2 or mRNA-1273, respectively, to prevent one COVID-19 hospitalisation over a 6-month period. Hospitalisations prevented per million BNT162b2 and mRNA-1273 doses administered are 32.0 and 23.3, respectively (table 1).

    SAE rates reported from manufacturer-provided data

    Of the 12 SAEs reported in the intervention arm of the randomised controlled trial (RCT) for BNT162b2 (n=5055), three were found by blinded investigators to be attributable to the vaccine, providing a rate of 1 in 1685 (3/5055).19 The three SAEs considered vaccine related included: moderate persistent tachycardia, moderate transient elevated hepatic enzymes and mild elevated hepatic enzymes.19 Based on 31 207 in this age group needing to receive the first BNT162b2 booster to prevent one hospitalisation over a 6-month period, the expected SAE rate is 18.5 (3/5055*31 207). (Table 1A) Per million doses administered, the SAE rate is 593.5. Although the safety populations were small, we also reviewed SAEs reported from these cohorts. Pfizer reported 1/306 but the event was not considered related to the vaccine (1/306=0.3%). Similarly, Moderna found that none of the five SAEs experienced by 4 of 344 participants50 in its safety population (4/344=1.2%)3 were attributable to the vaccine, thus our SAE estimates rely on the only available RCT data (BNT162b2).

    Reactogenicity rates

    According to self-report data, side effects from the booster dose prevent on average 28.3% of mRNA vaccine recipients from being able to carry out normal daily activities, typically the day after vaccination.55 Sponsor-reported rates from the safety studies for grade ≥3 reactogenicity are 1 in 22 (14/306)50 for the BNT162b2 booster to 1 in 9 (18/167)50 for the mRNA-1273 booster. Per million third doses, reactogenicity rates are therefore 45 751.6–107 784.4, respectively (table 1B). Per COVID-19 hospitalisation prevented over 6 months in adults aged 18–29 years, the expected number of grade ≥3 reactogenicity cases is therefore 1429.7 (45 751.6/32.0) to 4625.9 (107 784.4/23.3), respectively.

    In those with a prior SARS-CoV-2 infection, postvaccination symptoms causing missed work or daily activities are reported twofold56 to threefold57 more often than those without a history of infection, a major concern given that seroprevalence among adults aged 18–49 years is now well above the February 2022 estimate of 63.7%.13 Conservatively assuming 63.7% as the proportion with a history of COVID-19 infection, and a twofold increased likelihood of systemic effects, expected grade ≥3 reactogenicity cases per single hospitalisation prevented would be at least 2340.5–7572.7 for BNT162b2 and mRNA-1273 boosters, respectively (table 1B). Even without taking into account prior infection, the proportion reporting to V-Safe being ‘unable to perform daily activities’ was between 20% and 40% depending on booster product, and higher among those receiving a heterologous booster.58

    Booster vaccine-associated myocarditis rates in university-age males 18–29 years

    The CDC estimated the rate of postbooster myocarditis during days 0–7 following BNT162b2 vaccine administration in males aged 16–17 years to be approximately 1 in 41 50051 using passive surveillance through the Vaccine Adverse Event Reporting System (VAERS), and approximately 1 in 500051 using active surveillance with the Vaccine Safety Datalink (VSD). In males aged 18–29 years, the postbooster myocarditis rate for both products combined using VAERS was reported to be 1 in 101 00052 (ages 18–24) to 1 in 208 00052 (ages 25–29) while the VSD rate was much higher at 1 in 14 20052 (mRNA-1273) to 1 in 21 00052 (BNT162b2). Two other population-based studies from the USA and Israel in males aged 18–39 years found the rate to be 1 in 7000 (147.0 per million third doses)53 to 9000 (126.6 per million third doses).54 In both of these studies, BNT162b2 was the vaccine administered prior to diagnosis. For our estimates, and assuming a precautionary stance, we have used active surveillance rates or population-based rates. For males aged 18–29 years we consider the rate 1 in 700053 to be the most reliable because the method relies on CDC definitions and databases.59 We also provide a 16–17 year-old rate because academic acceleration allows some older adolscents to attend college along with the freshman cohort, and in some cases students need to be vaccinated before their 18th birthday to enrol or be assigned to housing. For males aged 16–17 years, we use the VSD rate of 1 in 5000.51 In table 1C, we provide a range of myopericarditis estimates for consideration.

    Risk-benefit estimates

    The figures display benefits and harms per million third doses administered: SAEs (figure 1A), grade ≥3 reactogenicity (figure 1B) and myopericarditis (figure 1C). At this scale, and as shown in figure 1A, boosting young adults with BNT162b2 could cause 18.5 times more SAEs per million (593.5) than COVID-19 hospitalisations averted (32.0).

    To prevent one hospitalisation over 6 months by boosting 31 207–42 836 students, a large university campus may also expect 1429.7–4625.9 young adults to experience grade ≥3 reactogenicity disrupting daily activities or requiring medical care when vaccinated with a third dose of BNT162b2 or mRNA-1273, respectively. Per million third-doses of mRNA vaccine administered, between 45 751.6 and 107 784.4 cases of grade ≥3 reactogenicity may be created (figure 1B). Given that prior SARS-CoV-2 infection increases the rate of systemic reactions by twofold to threefold,56 57 the number of young adults expected to experience disruptions in their school and daily activities is likely to exceed 74 895.4 with BNT162b2 and 176 443.1 with mRNA-1273 (figure 1B).

    Per million third doses of mRNA vaccine administered, 23.3–32.0 hospitalisations may be averted while 47.6–147.0 cases of myo/pericarditis may be caused among young males aged 18–29 years (figure 1C). Thus, to prevent a single hospitalisation among young males aged 18–29 years, we estimate between 1.5 and 4.6 occurrences of myo/pericarditis (rates up to 1 in 700053) among males aged 18–29 years (figure 1C). For adolescents aged 16–17 years and using available data from CDC’s VSD,51 we expect 6.3 cases of myo/pericarditis among males and 1.4 among females. Thus, per single hospitalisation averted by boosting 31 207–42 836 young males in this age group, approximately 1.5–6.3 cases of myopericarditis may result.

    Most media reports, as well as a recent systematic review60 and expert opinion from the American College of Cardiology (ACC),61 present vaccination-associated myo/pericarditis as rare, (typically) ‘mild’ and followed by rapid recovery with anti-inflammatory treatment. The reviews have not framed vaccine-associated risks versus infection-associated risks using compatible denominators based on exposure (vaccination) and infection (seroprevalence), thus the infection-associated risks may have been overstated by at least a factor of 4 according to CDC estimates of the burden of COVID-19 illness.62 However, vaccine-associated myocarditis has been found to occur in as many as 1 in 2652 males aged 12–17 years and 1 in 1862 males aged 18–24 years after the second dose59 (and as high as 1/1300 after the second dose in a BNT162b2–mRNA-1273 combination).63 An Israeli study described one in five cases among 16–29 year-olds to be of intermediate severity, meaning these cases had persistent new/worsening abnormalities in left ventricular function, or persistent ECG anomalies, or frequent non-sustained ventricular arrhythmias without syncope.64 The CDC reported that 1200 of the 1314 verified myocarditis cases with known hospitalisation status following the primary series or booster had been hospitalised.65 Among adolescents, 69%66–80%67 of those diagnosed with vaccine-associated myo/pericarditis had findings consistent with cardiac inflammation on MRI testing 3–8 months after the second dose. The potential long-term impact of scar tissue on heart conduction remains unknown.66 67 Postvaccination myocarditis has been found to be equivalent to or exceed the risk of post-COVID myocarditis in males less than 40 years old despite the lack of seroprevalence-based estimates of COVID-associated myocarditis.68 Rare incidences of death in young males attributed to mRNA vaccine-induced myocarditis have also been reported.69 70

    Limitations of analysis

    These estimates have a number of limitations. First, our estimates rely on sponsor-reported and CDC summaries of AEs; we cannot account for failures to report small sample sizes, poor quality evidence subject to serious bias or loss to follow-up during the clinical trials. Second, our SAE estimate does not distinguish between specific types or the clinical significance of SAEs because of scarce data. The BNT162b2 RCT found more SAEs in the placebo group (24/5020) than the booster group (16/5055). However, blinded investigators attributed as vaccine-related three SAEs in the vaccine group (moderate persistent tachycardia, moderate transient elevated hepatic enzymes and mild elevated hepatic enzymes) and two SAEs in the placebo group (myocardial infarction and chest pain of unknown origin).19 Per million doses, the SAEs were therefore 593.5/million in the vaccine group vs 398.4/million in the placebo group, resulting in a risk difference of 195.1/million doses. The phase II/III BNT162b2 booster trial participants were of median age 42.0 and the company’s adolescent booster trial, for example, included only 78 individuals aged 16–17 years randomised to receive booster or placebo.71 Nevertheless, one male in this age group was hospitalised with myopericarditis after receiving a third dose of BNT162b2.71 It is possible that multiple severe side effects were reported by the same participant in the RCT trials and that the number of people impacted by such reactions is lower than our estimate. Hence, the causal relationship between our estimated SAEs and the COVID-19 vaccines needs to be approached with caution. We are extrapolating SAE data to young adults (18–29 years old) that were originally generated in clinical trials involving all age groups. However, studies have shown that younger people have a greater likelihood of vaccine-related AEs.72

    More generally, data limitations affect the CDC’s ability to evaluate both BNT162b2 and mRNA-1273. For example, the CDC’s Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) review50 noted ‘serious’ risk of bias for SAEs and ‘very low’ certainty of evidence (type 4) for all measures. While Pfizer conducted an RCT among 10 000 participants assigned 1:1 to booster or placebo, a sample size of 5000 is not sufficient to detect SAEs occurring at a rate of 1 in 7000 (such as vaccine-associated myo/pericarditis) among a subset of the population aged 18–29 years at highest risk. However, the trial data do suggest that the rate of AEs was higher among the intervention group than the placebo group (25.2% vs 6.8%).73 Moderna conducted a small, non-randomised safety study among 344 participants who elected to get a booster, and the reported SAEs were subject to serious risk of bias.50 ,4

    Despite these limitations, we believe that the data suggest caution is warranted. Haas et al 74 suggested that many systemic AEs in the RCTs (76% of systemic and 24% of local reactogenicity) may have been due to a nocebo effect—anxiety, expectations and background symptoms. It is very likely, however, that real-world severe or serious AEs may be greater than those reported in the RCT data because standard trials are underpowered to detect rare AEs and there may also be selection bias: those who had a reaction during the primary series may have a greater expectation of harmful side effects to the booster and are less likely to enrol in a trial. In fact, these data are usually collected after a drug has been approved and is on the market (phase IV clinical trial data). Such limitations show the need for more robust postmarketing data and ideally large, controlled trials to determine risks and benefits for any future booster doses, especially in younger age groups.

    Universities have not published cumulative AE rates on their COVID-19 dashboards, thus there is no current way to validate these estimates with real-world data. Even with the residual uncertainties, our risk-benefit assessment shows that it is at least plausible that expected individual harms outweigh benefits for young healthy people (ie, most young adults), and it is implausible that individual benefits significantly outweigh risks. Pfizer’s own booster data support this inference.71 In requesting the EUA for boosting adolescent males, the BNT162b2 risk-benefit analysis estimated 23–69 cases of myocarditis per 1 million booster doses administered and 29–69 COVID-19 hospitalisations averted,71 yet this estimate of 23–69 cases of myocarditis per million third BNT162b2 doses administered is now known to be an order of magnitude below the 200.3 per million reported by the US CDC among adolescents aged 16–17 years.51 Finally, our NNV with a booster dose to prevent one hospitalisation likely errs on the side of overestimating the effectiveness of the booster. We do not incorporate the protective effects of prior infection, for example. Recent studies have found rapid waning of effectiveness against hospitalisation during Omicron to <50% by 3–4 months,41 with some studies failing to detect any significant benefit against hospitalisation of a booster dose among those <40.21 If accurate, these data would render our booster risk-benefit analysis even less favourable.

    Five ethical arguments against university booster mandates

    Below, we present five ethical arguments against university booster mandates informed by our risk-benefit assessment and ethical analysis of mandatory policies to date. These arguments relate to (1) the importance of transparent, peer-reviewed risk-benefit analyses in policy, (2) the potential for net individual harm, (3) the lack of a proportionate public health benefit, (4) the lack of reciprocity in terms of compensation for vaccine-related harms and (5) the wider social harms of vaccine mandates.


    Risk-benefit assessment is essential to the ethical acceptability of public health policy, and transparent, peer-reviewed assessments help maintain trust in public health, especially in the context of controversial policies. There is an even stronger rationale for thorough and transparent risk-benefit assessment when interventions are mandated or when (given uncertainty or relevant population differences) some people might face harms not outweighed by individual benefits. In such cases, risk-benefit assessments should be stratified by demographic factors and updated as new data become available to reduce uncertainty. At a minimum, if an intervention is implemented despite significant uncertainty (especially if it is mandated), there is a strong ethical rationale to collect (controlled) data to resolve relevant uncertainties.

    An Omicron-era risk-benefit assessment published by the CDC and FDA could provide additional insight into the appropriateness of university booster mandates. However, such a risk-benefit assessment has not been published to date. Without such a formal analysis, professional associations (such as the ACC expert panel61) have been forced to infer from the literature and CDC’s own analyses. For example, the ACC expert panel produced a graphic displaying a favourable harms versus benefits ratio for the second dose among young adults aged 12–29 years.61 The ACC’s widely promoted graphic is tied to data presented by the CDC75 and relies on four key assumptions which bias the findings in favour of vaccination: (1) vaccine effectiveness of 95% over 120 days to prevent COVID-19 cases and hospitalisations; (2) myocarditis rates were derived from passive surveillance in VAERS instead of active surveillance available to the CDC (VSD) resulting in harms being underestimated by a factor of 1051 52; (3) harms and benefits were averaged across ages 12–29 when the risk may be highest among those aged 16–19 years51 52; and (4) hospitalisation rates were tied to May 2021 data, more than a year prior to the ACC’s review and pre-Omicron. Nevertheless, for adolescent males aged 12–17 years, the CDC estimated 56–69 myocarditis cases would be expected while 71 intensive care unit admissions could be averted.75

    It was foreseeable that the decision to recommend boosters for all adults (against the advice of the FDA panel) would be followed by booster mandates since pandemic vaccine mandates were already in place in many universities and colleges throughout the USA at the time.13 Universities rely on public health agencies such as the CDC for guidance. Thus, we maintain that if mandates remain then it is critically important to update public risk-benefit estimates for boosters among adults younger than 40, stratified by sex, comorbidity status and history of infection to provide evidence that the intervention confers an expected net benefit to younger individuals in the context of the prevailing SARS-CoV-2 variants and pre-existing immunity. Without this, it is problematic to repeatedly and emphatically claim that COVID-19 vaccines are ‘safe and effective’ without specific risk-benefit analyses for different age categories and with consideration for individual health status, including evidence of prior infection, because risks of both disease and vaccination are highly variable according to these factors.9 10

    Since there has not been any RCT specific to evaluating boosters in young adults, the CDC relied on data from an older cohort with a median age of 42.0–51.771 73 and incorrectly assumed that the benefits would also outweigh risks for younger age groups. As we have shown, it is likely that this assumption is incorrect. Under such uncertainties, ethical vaccine policymaking arguably requires transparency about scientific knowledge and uncertainties regarding vaccine risks and benefits (ie, even more transparency than where certainty is high), and at the very least allows for shared decision-making aligned with an appreciation of stratified risks instead of placing the emphasis on simplistic messaging.

    Transparent policymaking can encounter a ‘trust paradox’ in providing information about vaccine risks to the public. As noted by Petersen et al,76 governments have a perverse incentive to withhold negative information about vaccines since they are actively promoting such products and negative information about vaccines reduces vaccination uptake. And yet transparent disclosure about negative information (eg, side effects) helps sustain trust in health officials and reduces the politicisation of vaccines.77 Transparency may reduce the uptake of vaccination in the short term but will uphold trust in health authorities and vaccines in the longer term—just as open disclosure regarding clinical harms promotes trust in medicine.78 To address the ‘trust paradox’ in regulatory politics, and to maintain trust in government and scientific institutions, greater data accountability (in this case, a risk-benefit analysis) should precede any policy debate about mandates. Given concerns about pharmaceutical influence on the political process78 79 this should be facilitated by mechanisms to ensure independent scrutiny of regulatory science.79

    Potential net expected individual harm

    The reasonable possibility of a net harm to individuals (as presented in our risk-benefit assessment) should provide a strong basis to argue for the ethical case against booster mandates for young adults. Mandates at institutions of higher education serve the age group with one of the lowest public health burdens from COVID-19. Hence, boosters provide a low and transient impact on transmission and hospitalisation for an age group with a vague and unquantified prospect of benefit. Arguably, this has been considered by most universities and colleges and is the reason why most do not have booster mandates for the fall of 2022. In fact, this is also likely why European countries, including the UK, France, Germany, Norway, Sweden and Denmark (to our knowledge), never had university-implemented mandates.14 When the European Centre for Disease Prevention and Control (ECDC), a body serving some 300 million European residents, recommended boosters in November 2021, priority was focused on those over age 40.80 Taking a different view of the data, in the fall of 2021 the US CDC recommended boosters for all adults and recommended a second booster for all Americans aged 50 years or more for fall 2022.81 The ECDC, in contrast, recommended that first boosters be ‘offered’ with prioritisation for those over 40 years, and now recommends second boosters for the 2022 autumn campaign only for those over age 60 and those with an immunocompromised status or high-risk medical conditions.82

    Reflecting again to fall of 2021, the UK’s JCVI provides an example of using the potential for net harm to advise against the primary vaccination series for 12–15 year-olds.83 The JCVI argued that the potential benefit of vaccination in this age group was only ‘marginally greater than the potential known harms’, since healthy 12–15 year-olds are at very low risk of serious outcomes from COVID-19. Although it may be the case that the JCVI adopted worst-case estimates,84 such an approach reinforces the need to act judiciously under conditions of uncertainty where the clear benefits of an intervention are not confidently above the potential harms. Note also that they mention ‘potential known harms’ without taking into consideration potential long-term effects. The UK Health Ministers subsequently voted to offer a single dose of vaccination to adolescents aged 12–15 years in consideration of: ‘…the health and wider social benefits to this cohort’.85 A second dose was offered to those with underlying health conditions. There are important parallels between the JCVI decision and the outcome of the FDA panel that recommended against universal booster recommendations for adults in the USA in the fall of 2021: in both cases, the US and UK governments disregarded these recommendations. A key ethical difference is that the UK has not implemented any COVID-19 vaccine mandates at schools or universities, and the mandate proposed for care home and healthcare workers was withdrawn.86

    As noted above, blanket mandates ignore widely available critical data, such as the benefits of prior infection and data on adverse effects. These factors make an expected net harm now even more likely than when mandates began and make it more urgent to update COVID-19 vaccine policy. Policies for other vaccines have been updated following the accumulation of new data. For example, adult boosters for tetanus and diphtheria vaccines (though previously widely administered) have been shown to provide no benefit.87 Vaccines for influenza, dengue and rotavirus have been withdrawn or had strict limitations placed on their use in children due to unexpected harms.88 Adenovirus-vectored COVID-19 vaccines have been limited in their use due to thrombosis (especially in younger women).89 Uncertainties remain regarding mRNA vaccines, for example, related to their effects on menstruation and fertility,90 shingles91 or the overall safety of current formulations in younger adults and children as well as evidence in support of booster vaccination.92

    There are two other theoretical problems that could be factored into mandatory programmes from a precautionary standpoint: original antigenic sin and the non-specific effects of vaccines. Original antigenic sin refers to the decreased ability of an individual to respond to a new viral variant because the immune system has been ‘locked’ onto the original immunogen.93 While data have not shown this to occur with COVID-19 vaccine, it cannot yet be ruled out as an important side effect of repeat vaccination, including with the new bivalent booster. Non-specific effects of vaccination refer to the effects of a vaccine on overall health and all-cause mortality, which have been shown to differ based on the type of vaccine (eg, live vs non-live) and age/sex.94 95 Both of these theoretical issues are at the frontiers of our current knowledge of vaccinology and are rarely considered in the media and by the lay public. We cite these examples to support our main point: proportionality of mandates should account for uncertainty regarding evidence that benefits outweigh harms, especially as the marginal benefits of vaccination and boosting for young adults become vanishingly small with increased population immunity.

    Lack of proportionate public health benefit

    Proportionality, a key principle in public health ethics, requires that the benefits of a public health policy must be expected to outweigh harms, including harms arising from the restriction of individual liberty and basic human rights such as access to education and employment.1 5–8 86 Where mass vaccination involves harm to a minority of individuals, or coercion or undue inducements are used to increase vaccine uptake, proportionality requires that these considerations be outweighed by public health benefits, typically in the form of reduced transmission from vaccinated individuals to others.96

    COVID-19 booster mandates often involve a degree of coercion, including the threat of loss of access to education and free choice of occupation, disproportionately affecting disenfranchised groups.96 Contrary to those who restrict the concept of coercion to situations of a direct threat to something people should have access to as a matter of right,97 we endorse here a broader concept of coercion that includes situations of structural pressure that deprive people of reasonable options.98 ,99 To be ethically acceptable, such severe restrictions of individual liberty need to be justified by an individual benefit and by the expectation that vaccination reduces harm to others. Booster doses of COVID-19 vaccines provide limited lasting reduction in the probability of infection or transmission,27–29 hospitalisation41 and limited expected benefits to young healthy individuals, especially those who have already been infected.31–33 100–102 The net expected harms to individuals and the harms of coercive mandates themselves are not counterbalanced by a large public health benefit (and in fact may harm the public health through the attrition of healthcare workers); such harms and restrictions of liberty are therefore disproportionate and ethically unjustifiable.

    Failure of reciprocity

    The use of booster mandates raises an additional ethical problem of reciprocity for institutions of higher education and public health authorities.103 104 Most vaccines are covered in the USA105 and Canada106 by an injury compensation programme based on fair (reciprocal) compensation for those who experience a vaccine-related harm. Mandatory vaccines arguably require even stronger protections for individuals who experience consequences that lead to permanent harm107 because their free choice regarding vaccination has been limited. While institutions of higher education are mandating boosters, the US and Canadian compensation programmes have failed to uphold their social justice responsibility to injured individuals. In the USA, COVID-19 vaccines and therapeutics are processed by the Countermeasures Injury Compensation Program (CICP) which is designed to cover epidemics, pandemics and security threats as designated by the Secretary of Health and Human Services and as authorised by the Public Readiness and Emergency Preparedness (PREP) Act.105 As of 1 August 2022, thirty-seven claims have been denied compensation because ‘the standard of proof for causation was not met’ or ‘a covered injury was not sustained’.108 No claims have been paid out by the US CICP but one claim for anaphylaxis has been approved for compensation and payout is currently pending assessment of eligible expenses.108

    The federal US vaccine injury programme has failed to compensate but one COVID-19 vaccine-injured individual in the context of booster mandates in place at hundreds of US universities.108 It is also important to note that boosters have been granted an EUA by the FDA, but are still not fully approved.109 Thus, universities and colleges that mandate COVID-19 boosters are pressuring young adults to receive a vaccine that, in case of injury, has no transparent legal route to adequate compensation. In sum, one core precondition for vaccine mandates is a functioning and fair compensation programme, which has not been achieved for COVID-19 vaccines.

    Wider social harms

    Strong coercion may create significant social harms. COVID-19 vaccine mandates have generally involved a high degree of coercion, effectively ostracising unvaccinated individuals from society. University mandates involve significant coercion in that they exclude unvaccinated people from the benefits of university education (or employment) and thereby entail major infringements to free choice of occupation and freedom of association. When such mandates are not supported by a compelling public health justification and where exemptions are not easily available, the likelihood of reactance and negative social effects are increased.1 The social harms of university COVID-19 mandates have not been formally studied, but there is reason to think that they will be significant.1 Policies can have wide-ranging consequences for non-compliance, such as loss of employment, loss of internet use, restriction to off-campus versus on-campus housing, delays or refusal to process student housing requests, loss of enrolment, a hold placed on grades, inability to use recreational facilities to train or compete in sports, access to scholarships for competitive sports, registration for class and delays in ability to repay student loans after graduation. A number of young adults and professors affected by mandates have outlined publicly their perspectives and the social harms of these policies, such as loss of access to schooling and social services,110 psychosocial stress, reputational damage and lost income and threats of being disenrolled or deported.111 This punitive public health approach may also provoke reactance in young adults,1 with long-term negative consequences on trust in society and institutions and vaccine confidence in general, including vaccine hesitancy for routine paediatric and adult vaccines, a problem which predated the pandemic and is considered one of the WHO’s top 10 threats to global health.112

    Objections: possible rationales for mandates

    Despite the considerations above, proponents of university COVID-19 booster mandates might argue that such policies are justified (even if some individuals experience uncompensated harms) because they: (1) help normalise compliance with vaccination as a social duty (thereby promoting solidarity or provaccine attitudes that undermine antivaccination sentiment) and/or (2) help to increase the safety of the university environment or wider society. Mandates may help some people ‘feel better’, knowing that everyone in a crowd, dorm or classroom is vaccinated, that they are among peers who have ‘done the right thing’ and ‘care about the safety of others’. For instance, some faculty and staff may ‘feel protected’ by the new booster mandate introduced at Western University in Ontario, Canada, on 22 August 2022.113 From this perspective, if a majority of university policymakers (whether clinical advisory group members, administrators and/or professors) or students believe that vaccination should be socialised to promote solidarity, counteract antivaccination sentiment or create a safe environment, then such beliefs (and values) should guide policy.

    However, even if many people hold such beliefs and even if such goals are laudable, policy must be predicated on methods and models which are open to public scrutiny. Risk-benefit assessments should remain objective and avoid the use of some people feeling better or safer to justify behavioural rules with sanctions for non-compliance in the absence of rational justification. While many vaccines do improve group safety by reducing transmission, the current generation of COVID-19 vaccines does not provide significant lasting effects of this kind, and repeated doses appear to provide diminishing benefits (in terms of reduced infection) per dose, especially among young adults.114 It therefore makes little sense to claim, as a matter of policy, that COVID-19 vaccination is a prosocial act or that the unvaccinated are a disproportionate threat to others. Moreover, it is unclear whether mandating COVID-19 boosters will produce a net positive effect on provaccine sentiment in society—in fact, booster mandates may increase antivaccination beliefs and reduced uptake of other (non-coronavirus) vaccines.1 86 96 As highlighted above, there are also wider social harms of policies that purport to reduce transmission of a ubiquitous virus: such policies may create a fear of infection among young healthy people (out of proportion to the actual risks) and contribute to worsening mental health, an issue which predates the pandemic.115

    Moreover, the claim that the socialisation of compliance with public health measures can justify those measures is problematic for three other reasons. First, such an argument is circular: compliance should not be an end itself; policy must be justified by the expectation of public health benefit. Second, people have different attitudes to compliance depending on their values (eg, the views regarding the importance of individual liberty) and experiences (eg, those with low baseline levels of trust in public health due to negative experiences of health professionals or government agencies). Policies that require people to comply against their values and preferences require ethical justification, especially where voluntary compliance is likely to be lower among those who are disempowered (eg, students) or marginalised for other reasons,5 116 for example, those from social groups which have been mistreated by government agencies or by the medical system in the past, including in the context of research.117 Third, the socialisation argument is based, in part, on concepts of civic duty and responsibility to others. Pushing for boosters even when these will not significantly contribute to overall risk reduction runs counter to the responsible use of public resources. Policies that encourage waste of valuable healthcare resources, to make some feel better, are sending a distorted message about important societal obligations.

    The proclivity for university vaccine mandates may also reflect harmful trends towards intolerance in university bureaucracies that value compliance over individual freedoms. Mandates, by their nature, encourage conformity and acquiescence to authority, and exclude those with different views or values. Though universities might take pride in being places that permit the free exchange of ideas, mandates reduce the scope for reasoned debate regarding scientific uncertainties or conflicts of ethical values.118 For example, how many universities have held public debates about mandatory COVID-19 vaccination? To our knowledge, very few such debates have taken place in North American institutions. We are aware of only one academic event119 which some of us organised, in which mandates were critically debated. Sanctions for lack of full vaccination imposed on university professors who publicly voiced their opposition against mandates could arguably also have been intended to suppress public debate or be interpreted as such.

    Implications for broader COVID-19 vaccine mandates for youth in schools and other institutions

    The arguments presented above are relevant to third, fourth or fifth-dose booster mandates and to university or school policies that maintain primary two-dose COVID-19 vaccine mandates in 2022 in the face of high rates of previous SARS-CoV-2 infection.13 Two-dose mandates are being upheld in at least 1000 universities and colleges across the USA, far more than the 300 or so maintaining booster mandates,2 and also some primary and secondary schools in the nation’s largest public school systems120 which instituted mandates then extended the deadline for compliance when it was apparent that serious inequities in access to education would result.121 It is even harder to justify a two-dose primary vaccine mandate in late 2022 than when such policies began in mid-2021.46 This rationale is weak at best and wrong at worst. Consistent with our argument above, the now high prevalence of prior infection, data regarding the lack of sustained transmission reduction by current vaccines and the age at peak risk for myo/pericarditis being young adults aged 16–17 years51 all undermine the case for two-dose vaccine mandates. Students heading to colleges with mandates must currently upload proof of vaccination in order to enrol or be assigned to on-campus housing. We would therefore urge universities and schools to rescind all COVID-19 vaccine mandates. Strong statements in support of mandates made in 2021 by organisations such as the Association of Bioethics Program Directors in North America,122 the American Civil Liberties Union123 and the Ontario Human Rights Commission124 are now obsolete. Such organisations have an ethical obligation to revise these public statements and consider whether they are valid in light of current data.

    The continued policy of two-dose mandates may represent status quo bias: when indiscriminate regulations are normalised they often remain even when it has no (current) rational basis. The more rules, the more paperwork and cumbersome ‘busy work’ administrators and young students and professionals need to complete. Yet rules come with consequences: how much are universities, corporations, consulting firms and the military paying in staff time to monitor and maintain vaccine mandates? How much time and energy are young adults using to comply with these policies? How much frustration and psychosocial stress is this causing? What are the consequences of attrition of healthcare workers and military service members at times when the labour market is tight and recruitment is difficult? When vaccine mandates are unethical, individuals may have an ethical duty to oppose them, in part to promote tolerance and prevent further bureaucratic encroachment and disenfranchisement of individuals with reasoned arguments against such mandates. Finally, we argue that institutions have an ethical duty to evaluate the effectiveness of such programmes if the status quo is to be maintained.


    Based on public data provided by the CDC,19 we estimate that in the fall of 2022 at least 31 207–42 836 young adults aged 18–29 years must be boosted with an mRNA vaccine to prevent one Omicron-related COVID-19 hospitalisation over 6 months. Given the fact that this estimate does not take into account the protection conferred by prior infection or a risk adjustment for comorbidity status, this should be considered a conservative and optimistic assessment of benefit. Our estimate shows that university COVID-19 vaccine mandates are likely to cause net expected harms to young healthy adults—for each hospitalisation averted we estimate approximately 18.5 SAEs and 1430–4626 disruptions of daily activities—that is not outweighed by a proportionate public health benefit. Serious COVID-19 vaccine-associated harms are not adequately compensated for by current US vaccine injury systems. As such, these severe infringements of individual liberty and human rights are ethically unjustifiable.

    Mandates are also associated with wider social harms. The fact that such policies were implemented despite controversy among experts and without updating the sole publicly available risk-benefit analysis19 to the current Omicron variants nor submitting the methods to public scrutiny suggests a profound lack of transparency in scientific and regulatory policy making. These findings have implications for mandates in other settings such as schools, corporations, healthcare systems and the military. Policymakers should repeal COVID-19 vaccine mandates for young adults immediately and ensure pathways to compensation to those who have suffered negative consequences from these policies. Regulatory agencies should facilitate independent scientific analysis through open access to participant-level clinical trial data to allow risk-stratified and age-stratified risk-benefit analyses of any new vaccines prior to issuing recommendations.125 This is needed to begin what will be a long process of rebuilding trust in public health.

    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.html23table03a; 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.

    Ethics statements

    Patient consent for publication

    Not applicable.


      2. Bardosh K , 
      3. de Figueiredo A , 
      4. Gur-Arie R , et al 
      . The unintended consequences of COVID-19 vaccine policy: why mandates, passports and restrictions may cause more harm than good. BMJ Glob Health 2022;7(5):e008684.doi:10.1136/bmjgh-2022-008684 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35618306 Abstract/FREE Full TextGoogle Scholar
      2. Golembeski D 
      . These Are the Colleges Requiring Vaccine Boosters Now. Updated March 18, 2022. Available at What Colleges Require the COVID-19 Vaccine? | BestColleges. Available: https://www.bestcolleges.com/news/2021/10/11/list-of-colleges-that-require-covid-19-vaccine/ [Accessed 30 Aug 2022].Google Scholar
      2. Burt C 
      . Calls for end to COVID-19 vaccine booster mandates growing in higher ed, 2022. Available: https://universitybusiness.com/calls-for-end-to-covid-19-vaccine-booster-mandates-growing-in-higher-ed/ [Accessed 28 Mar 2022].Google Scholar
      2. Block J 
      . US college covid-19 vaccine mandates don’t consider immunity or pregnancy, and may run foul of the law. BMJ 2021;373:n1397.doi:10.1136/bmj.n1397 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34078619 FREE Full TextGoogle Scholar
      1. World Health Organization
      . COVID-19 and mandatory vaccination: ethical considerations: policy brief, 2022. Available: https://www.who.int/publications/i/item/WHO-2019-nCoV-Policy-brief-Mandatory-vaccination-2022.1 [Accessed 20 Aug 2022].Google Scholar
      2. Savulescu J 
      . Good reasons to vaccinate: mandatory or payment for risk? J Med Ethics 2021;47(2):78–85.doi:10.1136/medethics-2020-106821 pmid:http://www.ncbi.nlm.nih.gov/pubmed/33154088 Abstract/FREE Full TextGoogle Scholar
      2. Giubilini A , 
      3. Savulescu J , 
      4. Wilkinson D 
      . COVID-19 vaccine: vaccinate the young to protect the old? J Law Biosci 2020;7(1).doi:10.1093/jlb/lsaa050 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32959006 PubMedGoogle Scholar
      2. Williams BM 
      . The ethics of selective mandatory vaccination for COVID-19. Public Health Ethics 2022;15(1):74–86.doi:10.1093/phe/phab028 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35702643 PubMedGoogle Scholar
      2. Romero Starke K , 
      3. Reissig D , 
      4. Petereit-Haack G , et al 
      . The isolated effect of age on the risk of COVID-19 severe outcomes: a systematic review with meta-analysis. BMJ Glob Health 2021;6(12):e006434.doi:10.1136/bmjgh-2021-006434 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34916273 Abstract/FREE Full TextGoogle Scholar
      2. Choi JH , 
      3. Choi S-H , 
      4. Yun KW 
      . Risk factors for severe COVID-19 in children: a systematic review and meta-analysis. J Korean Med Sci 2022;37(5):e35.doi:10.3346/jkms.2022.37.e35 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35132841 PubMedGoogle Scholar
      2. Ughi N , 
      3. Del Gaudio F , 
      4. Dicuonzo A , et al 
      . Host factors and history of SARS-CoV-2 infection impact the reactogenicity of BNT162b2 mRNA vaccine: results from a cross-sectional survey on 7,014 workers in healthcare. Eur Rev Med Pharmacol Sci 2021;25(24):7985–96.doi:10.26355/eurrev_202112_27649 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34982462 PubMedGoogle Scholar
      2. Karlstad Øystein , 
      3. Hovi P , 
      4. Husby A , et al 
      . SARS-CoV-2 vaccination and myocarditis in a Nordic cohort study of 23 million residents. JAMA Cardiol 2022;7(6):600–12.doi:10.1001/jamacardio.2022.0583 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35442390 PubMedGoogle Scholar
      2. Clarke KE , 
      3. Jones JM , 
      4. Deng Y 
      . Seroprevalence of infection-induced SARS-CoV-2 antibodies — United States, September 2021–February 2022. MMWR Morb Mortal Wkly Rep 2022;(71).Google Scholar
      2. Havergal C 
      . No Plans to Require Vaccines at English Universities. Inside Higher Ed, 2021. Available: https://www.insidehighered.com/news/2021/08/06/no-plans-require-vaccines-english-universities [Accessed 28 Mar 2022].Google Scholar
      1. Centers for Disease Control and Prevention
      . Joint CDC and FDA statement on vaccine boosters, 2021. Available: https://www.cdc.gov/media/releases/2021/s-07082021.html [Accessed 20 Aug 2022].Google Scholar
      1. Food and Drug Administration
      . Emergency use Authorization (EUA) for an unapproved product, 2021. Available: https://www.fda.gov/media/152432/download page 5 [Accessed 28 Mar 2022].Google Scholar
      2. Krause PR , 
      3. Fleming TR , 
      4. Peto R , et al 
      . Considerations in boosting COVID-19 vaccine immune responses. Lancet 2021;398(10308):pp1377–80.doi:10.1016/S0140-6736(21)02046-8 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34534516 PubMedGoogle Scholar
      2. Doshi P , 
      3. Godlee F , 
      4. Abbasi K 
      . Covid-19 vaccines and treatments: we must have RAW data, now. BMJ 2022;376.doi:10.1136/bmj.o102 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35045956 PubMedGoogle Scholar
      2. Oliver S 
      . Updates to the evidence to recommendation framework: Pfizer-BioNTech and Moderna COVID-19 vaccine booster doses. ACIP meeting. November 19, 2021. (slides 26, 29, 30, 31, 37), 2021. Available: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-19/06-COVID-Oliver-508.pdf [Accessed 28 Mar 2022].Google Scholar
      2. Andrews N , 
      3. Stowe J , 
      4. Kirsebom F , et al 
      . Effectiveness of COVID-19 booster vaccines against COVID-19-related symptoms, hospitalization and death in England. Nat Med 2022;28(4):831-837.doi:10.1038/s41591-022-01699-1 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35045566 PubMedGoogle Scholar
      2. Bar-On YM , 
      3. Goldberg Y , 
      4. Mandel M , et al 
      . Protection against Covid-19 by BNT162b2 booster across age groups. N Engl J Med 2021;385(26):2421-2430.doi:10.1056/NEJMoa2115926 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34879188 PubMedGoogle Scholar
      2. Link-Gelles R , 
      3. Levy ME , 
      4. Gaglani M , et al 
      . Effectiveness of 2, 3, and 4 COVID-19 mRNA Vaccine Doses Among Immunocompetent Adults During Periods when SARS-CoV-2 Omicron BA.1 and BA.2/BA.2.12.1 Sublineages Predominated – VISION Network, 10 States, December 2021-June 2022. MMWR Morb Mortal Wkly Rep 2022;71(29):931–9.doi:10.15585/mmwr.mm7129e1 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35862287 CrossRefPubMedGoogle Scholar
      2. Li X , 
      3. Lai FTT , 
      4. Chua GT , et al 
      . Myocarditis following COVID-19 BNT162b2 vaccination among adolescents in Hong Kong. JAMA Pediatr 2022;176(6):612–4.doi:10.1001/jamapediatrics.2022.0101 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35212709 PubMedGoogle Scholar
      2. Wallace M 
      . Vaccine booster: Benefits-Risk discussion, 2021. Available: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-9-23/02-COVID-Wallace-508.pdf [Accessed 28 Sep 2022].Google Scholar
      2. Andrews N , 
      3. Stowe J , 
      4. Kirsebom F 
      . Covid-19 vaccine effectiveness against the omicron (B.1.1.529) variant. N Eng J Med.doi:10.1056/NEJMoa2119451 Google Scholar
      2. Accorsi EK , 
      3. Britton A , 
      4. Fleming-Dutra KE , et al 
      . Association between 3 doses of mRNA COVID-19 vaccine and symptomatic infection caused by the SARS-CoV-2 omicron and delta variants. JAMA 2022;327(7):639–51.doi:10.1001/jama.2022.0470 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35060999 PubMedGoogle Scholar
      2. Singanayagam A , 
      3. Hakki S , 
      4. Dunning J , et al 
      . Community transmission and viral load kinetics of the SARS-CoV-2 delta (B.1.617.2) variant in vaccinated and unvaccinated individuals in the UK: a prospective, longitudinal, cohort study. Lancet Infect Dis 2022;22(2):183–95.doi:10.1016/S1473-3099(21)00648-4 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34756186 PubMedGoogle Scholar
      2. Boucau J , 
      3. Marino C , 
      4. Regan J , et al 
      . Duration of shedding of culturable virus in SARS-CoV-2 omicron (BA.1) infection. N Engl J Med 2022;387(3):275–7.doi:10.1056/NEJMc2202092 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35767428 PubMedGoogle Scholar
      1. Centers for Disease Control and Prevention
      . Omicron variant: what you need to know. Available: https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html [Accessed 20 Aug 2022].Google Scholar
      2. Mulligan CB , 
      3. Arnott RD 
      . Non-COVID excess deaths, 2020-21: collateral damage of policy choices? National Bureau of economic research, 2022. Available: https://www.nber.org/system/files/working_papers/w30104/w30104.pdf [Accessed 20 Aug 2022].Google Scholar
      2. Pilz S , 
      3. Theiler-Schwetz V , 
      4. Trummer C , et al 
      . SARS-CoV-2 reinfections: overview of efficacy and duration of natural and hybrid immunity. Environ Res 2022;209:112911.doi:10.1016/j.envres.2022.112911 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35149106 CrossRefPubMedGoogle Scholar
      2. Wei J , 
      3. Pouwels KB , 
      4. Stoesser N , et al 
      . Antibody responses and correlates of protection in the general population after two doses of the ChAdOx1 or BNT162b2 vaccines. Nat Med 2022;28(5):1072–82.doi:10.1038/s41591-022-01721-6 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35165453 PubMedGoogle Scholar
      2. Nordström P , 
      3. Ballin M , 
      4. Nordström A 
      . Risk of SARS-CoV-2 reinfection and COVID-19 hospitalisation in individuals with natural and hybrid immunity: a retrospective, total population cohort study in Sweden. Lancet Infect Dis 2022;22(6):p781–90.doi:10.1016/S1473-3099(22)00143-8 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35366962 PubMedGoogle Scholar
      2. Offit PA 
      . Covid-19 Boosters – Where from Here? N Engl J Med 2022;386(17):1661–2.doi:10.1056/NEJMe2203329 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35417633 CrossRefPubMedGoogle Scholar
      2. Crist C 
      . Fauci: ‘Many, Many’ More Vaccine Mandates Needed to End Pandemic. WebMD, 2021. Available: https://www.webmd.com/vaccines/covid-19-vaccine/news/20210913/fauci-many-more-vaccine-mandates-needed-to-end-pandemic [Accessed 30 Aug 2022].Google Scholar
      2. Heriot GS , 
      3. Jamrozik E 
      . Imagination and remembrance: what role should historical epidemiology play in a world bewitched by mathematical modelling of COVID-19 and other epidemics? Hist Philos Life Sci 2021;43(2):81.doi:10.1007/s40656-021-00422-6 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34100155 CrossRefPubMedGoogle Scholar
    1. Set i bakspejlet fik vi ikke meget ud af at vaccinere børnene, erkender Brostrøm. TV2, 2022. Available: https://nyheder.tv2.dk/samfund/2022-06-22-set-i-bakspejlet-fik-vi-ikke-meget-ud-af-at-vaccinere-boernene-erkender-brostroem [Accessed 30 Aug 2022].Google Scholar
    2. Vaccination mod covid-19. Sundhedsstyrelsen. Available: https://www.sst.dk/da/corona/vaccination [Accessed 30 Aug 2022].Google Scholar
    3. JCVI statement on the COVID-19 booster vaccination programme for autumn 2022: update 15 August 2022, 2022. Available: www.gov.uk [Accessed 22 Aug 2022].Google Scholar
      1. COVID-19 Forecasting Team
      . Variation in the COVID-19 infection–fatality ratio by age, time, and geography during the pre-vaccine era: a systematic analysis. The Lancet 2022;399(10334):1469–88.doi:10.1016/S0140-6736(21)02867-1 CrossRefPubMedGoogle Scholar
      2. Collie S , 
      3. Nayager J , 
      4. Bamford L , et al 
      . Effectiveness and durability of the BNT162b2 vaccine against omicron sublineages in South Africa. N Engl J Med 2022;387(14):1332–3.doi:10.1056/NEJMc2210093 pmid:http://www.ncbi.nlm.nih.gov/pubmed/36103455 PubMedGoogle Scholar
      2. Kirsebom FCM , 
      3. Andrews N , 
      4. Stowe J , et al 
      . COVID-19 vaccine effectiveness against the omicron (BA.2) variant in England. Lancet Infect Dis 2022;22(7):931–3.doi:10.1016/S1473-3099(22)00309-7 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35623379 CrossRefPubMedGoogle Scholar
      2. Altarawneh HN , 
      3. Chemaitelly H , 
      4. Ayoub HH , et al 
      . Effects of previous infection and vaccination on symptomatic omicron infections. N Engl J Med 2022;387(1):21–34.doi:10.1056/NEJMoa2203965 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35704396 PubMedGoogle Scholar
      2. Al-Aly Z , 
      3. Bowe B , 
      4. Xie Y 
      . Long COVID after breakthrough SARS-CoV-2 infection. Nat Med 2022;28(7):1461–7.doi:10.1038/s41591-022-01840-0 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35614233 CrossRefPubMedGoogle Scholar
      2. Pham B , 
      3. Rios P , 
      4. Radhakrishnan A , et al 
      . Comparative-Effectiveness research of COVID-19 treatment: a rapid scoping review. BMJ Open 2022;12(6):e045115.doi:10.1136/bmjopen-2020-045115 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35947494 PubMedGoogle Scholar
      2. Krug A , 
      3. Stevenson J , 
      4. Høeg TB 
      . BNT162b2 vaccine-associated Myo/Pericarditis in adolescents: a stratified risk-benefit analysis. Eur J Clin Invest 2022;52(5):e13759.doi:10.1111/eci.13759 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35156705 PubMedGoogle Scholar
      2. Trobajo-Sanmartín C , 
      3. Miqueleiz A , 
      4. Guevara M 
      . Comparison of the risk of hospitalisation and severe disease among co-circulating SARS-CoV-2 variants. J Infect Dis 2022:jiac385.doi:10.1093/infdis/jiac385 Google Scholar
      2. Rosenblum HG , 
      3. Gee J , 
      4. Liu R , et al 
      . Safety of mRNA vaccines administered during the initial 6 months of the US COVID-19 vaccination programme: an observational study of reports to the vaccine adverse event reporting system and v-safe. Lancet Infect Dis 2022;22(6):802–12.doi:10.1016/S1473-3099(22)00054-8 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35271805 PubMedGoogle Scholar
      1. National Institutes of Health
      2. National Institute of Allergy and Infectious Diseases
      . Rules and policies for clinical research: safety reporting and pharmacovigilance.. Available: https://www.niaid.nih.gov/research/dmid-safety-reporting-pharmacovigilance [Accessed 30 Aug 2022].Google Scholar
      1. CDC
      . Grading of recommendations, assessment, development, and evaluation (grade): Pfizer-BioNTech, Moderna, and Janssen COVID-19 booster doses, 2021. Available: https://www.cdc.gov/vaccines/acip/recs/grade/covid-19-booster-doses.html#table-03a Google Scholar
      2. Shimabukuro T 
      . Update on myocarditis following mRNA COVID-29 vaccination. Advisory Committee on immunization practices (ACIP). slides 10 and 23, 2022. Available: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-06-22-23/03-covid-shimabukuro-508.pdf [Accessed on August 20, 2022].Google Scholar
      2. Shimabukuro T 
      . Myocarditis following mRNA COVID-19 vaccination. Advisory Committee on immunization practices (ACIP), 2022. Available: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2022-07-19/03-COVID-Shimabukuro-508.pdf [Accessed 20 Aug 2022].Google Scholar
      2. Sharff KA , 
      3. Dancoes DM , 
      4. Longueil JL , et al 
      . Myopericarditis after COVID-19 booster dose vaccination. Am J Cardiol 2022;172:165–6.doi:10.1016/j.amjcard.2022.02.039 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35351285 CrossRefPubMedGoogle Scholar
      2. Friedensohn L , 
      3. Levin D , 
      4. Fadlon-Derai M , et al 
      . Myocarditis following a third BNT162b2 vaccination dose in military recruits in Israel. JAMA 2022;327(16):1611–2.doi:10.1001/jama.2022.4425 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35297962 CrossRefPubMedGoogle Scholar
      2. Hause AM , 
      3. Baggs J , 
      4. Gee J , et al 
      . Safety Monitoring of an Additional Dose of COVID-19 Vaccine – United States, August 12-September 19, 2021. MMWR Morb Mortal Wkly Rep 2021;70(39):1379–84.doi:10.15585/mmwr.mm7039e4 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34591835 CrossRefPubMedGoogle Scholar
      2. Beatty AL , 
      3. Peyser ND , 
      4. Butcher XE , et al 
      . Analysis of COVID-19 vaccine type and adverse effects following vaccination. JAMA Netw Open 2021;4(12):e2140364.doi:10.1001/jamanetworkopen.2021.40364 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34935921 PubMedGoogle Scholar
      2. Monforte A , 
      3. Tavelli A , 
      4. Perrone PM 
      . Association between previous infection with SARS CoV-2 and the risk of self-reported symptoms after mRNA BNT162b2 vaccination: data from 3,078 health care workers. EClinicalMedicine.doi:10.1016/j.eclinm.2021.100914 Google Scholar
      2. Hause AM , 
      3. Baggs J , 
      4. Marquez P , et al 
      . Safety Monitoring of COVID-19 Vaccine Booster Doses Among Adults – United States, September 22, 2021-February 6, 2022. MMWR Morb Mortal Wkly Rep 2022;71(7):249–54.doi:10.15585/mmwr.mm7107e1 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35176008 CrossRefPubMedGoogle Scholar
      2. Sharff KA , 
      3. Dancoes DM , 
      4. Longueil JL , et al 
      . Risk of myopericarditis following COVID-19 mRNA vaccination in a large integrated health system: a comparison of completeness and timeliness of two methods. Pharmacoepidemiol Drug Saf 2022;31(8):921–5.doi:10.1002/pds.5439 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35404496 CrossRefPubMedGoogle Scholar
      2. Morello R , 
      3. Pepe M , 
      4. Martino L , et al 
      . COVID-19 review shows that benefits of vaccinating children and adolescents appear to outweigh risks of post-vaccination myopericarditis. Acta Paediatr 2022;111(10):1846–52.doi:10.1111/apa.16462 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35735066 PubMedGoogle Scholar
      1.  Writing Committee, 
      2. Gluckman TJ , 
      3. Bhave NM , et al 
      . 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection, and return to play: a report of the American College of cardiology solution set oversight Committee. J Am Coll Cardiol 2022;79(17):1717–56.doi:10.1016/j.jacc.2022.02.003 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35307156 CrossRefPubMedGoogle Scholar
      1. Centers for Disease Control and Prevention
      . Estimated COVID-19 burden, 2022. Available: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/burden.html [Accessed 24 Aug 2022].Google Scholar
      2. Buchan SA , 
      3. Seo CY , 
      4. Johnson C , et al 
      . Epidemiology of myocarditis and pericarditis following mRNA vaccination by vaccine product, schedule, and interdose interval among adolescents and adults in Ontario, Canada. JAMA Netw Open 2022;5(6):e2218505.doi:10.1001/jamanetworkopen.2022.18505 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35749115 PubMedGoogle Scholar
      2. Witberg G , 
      3. Barda N , 
      4. Hoss S , et al 
      . Myocarditis after Covid-19 vaccination in a large health care organization. N Engl J Med Overseas Ed 2021;385(23):2132–9.doi:10.1056/NEJMoa2110737 Google Scholar
      2. Shimabukuro T 
      . Update on myocarditis following mRNA COVID-19 vaccination. vaccines and related biologic products Advisory Committee (VRBPAC), 2022. Available: https://www.fda.gov/media/159007/download [Accessed 12 Jul 2022].Google Scholar
      2. Schauer J , 
      3. Buddhe S , 
      4. Gulhane A 
      . Persistent cardiac MRI findings in a cohort of adolescents with post COVID-19 mRNA vaccine myopericarditis. The J of Pediatrics 2022;245:233–7.doi:10.1016/j.jpeds.2022.03.032 Google Scholar
      2. Hadley SM , 
      3. Prakash A , 
      4. Baker AL , et al 
      . Follow-Up cardiac magnetic resonance in children with vaccine-associated myocarditis. Eur J Pediatr 2022;181(7):2879–83.doi:10.1007/s00431-022-04482-z pmid:http://www.ncbi.nlm.nih.gov/pubmed/35482094 PubMedGoogle Scholar
      2. Patone M , 
      3. Mei XW , 
      4. Handunnetthi L 
      . Risk of myocarditis following sequential COVID-19 vaccinations by age and sex. Circulation 2022.doi:10.1161/CIRCULATIONAHA.122.059970 Google Scholar
      2. Mevorach D , 
      3. Anis E , 
      4. Cedar N , et al 
      . Myocarditis after BNT162b2 mRNA vaccine against Covid-19 in Israel. N Engl J Med 2021;385(23):2140–9.doi:10.1056/NEJMoa2109730 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34614328 PubMedGoogle Scholar
      2. Choi S , 
      3. Lee S , 
      4. Seo J-W , et al 
      . Myocarditis-induced sudden death after BNT162b2 mRNA COVID-19 vaccination in Korea: case report focusing on histopathological findings. J Korean Med Sci 2021;36(40):e286.doi:10.3346/jkms.2021.36.e286 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34664804 CrossRefPubMedGoogle Scholar
    4. CBER assessment of a single booster dose of the Pfizer-BioNTech COVID-19 vaccine (0.3 mL) administered to individuals 16 to 17 years of age after completion of a primary vaccination series with the Pfizer-BioNTech COVID-19 vaccine or COMIRNATY, 2021. Available: https://www.fda.gov/media/154869/download [Accessed 24 Aug 2022].Google Scholar
      2. Loosen SH , 
      3. Bohlken J , 
      4. Weber K , et al 
      . Factors associated with Non-Severe adverse reactions after vaccination against SARS-CoV-2: a cohort study of 908,869 outpatient vaccinations in Germany. Vaccines 2022;10(4). doi:doi:10.3390/vaccines10040566. [Epub ahead of print: 06 04 2022].pmid:http://www.ncbi.nlm.nih.gov/pubmed/35455315 PubMedGoogle Scholar
      2. Perez JL 
      . Efficacy & Safety of BNT162b2 booster – C4591031 2 month interim analysis. ACIP, 2021. Available: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-19/02-COVID-Perez-508.pdf [Accessed 24 Aug 2022].Google Scholar
      2. Haas JW , 
      3. Bender FL , 
      4. Ballou S , et al 
      . Frequency of adverse events in the placebo arms of COVID-19 vaccine trials: a systematic review and meta-analysis. JAMA Netw Open 2022;5(1):e2143955.doi:10.1001/jamanetworkopen.2021.43955 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35040967 PubMedGoogle Scholar
      2. Gargano JW , 
      3. Wallace M , 
      4. Hadler SC , et al 
      . Use of mRNA COVID-19 Vaccine After Reports of Myocarditis Among Vaccine Recipients: Update from the Advisory Committee on Immunization Practices – United States, June 2021. MMWR Morb Mortal Wkly Rep 2021;70(27):977–82.doi:10.15585/mmwr.mm7027e2 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34237049 CrossRefPubMedGoogle Scholar
      2. Petersen MB , 
      3. Bor A , 
      4. Jørgensen F , et al 
      . Transparent communication about negative features of COVID-19 vaccines decreases acceptance but increases trust. Proc Natl Acad Sci U S A 2021;118(29):e2024597118.doi:10.1073/pnas.2024597118 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34292869 Abstract/FREE Full TextGoogle Scholar
      2. Witman AB , 
      3. Park DM , 
      4. Hardin SB 
      . How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996;156(22):2565–9.pmid:http://www.ncbi.nlm.nih.gov/pubmed/8951299 CrossRefPubMedWeb of ScienceGoogle Scholar
      2. Abraham J 
      . The pharmaceutical industry as a political player. Lancet 2002;360(9344):1498–502.doi:10.1016/S0140-6736(02)11477-2 pmid:http://www.ncbi.nlm.nih.gov/pubmed/12433532 CrossRefPubMedWeb of ScienceGoogle Scholar
      2. Jorgensen PD 
      . Pharmaceuticals, political money, and public policy: a theoretical and empirical agenda. J Law Med Ethics 2013;41(3):561–70.doi:10.1111/jlme.12065 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24088146 PubMedGoogle Scholar
    5. Ecdc and EMA highlight considerations for additional and booster doses of COVID-19 vaccines. European centre for disease prevention and control, 2021. Available: https://www.ecdc.europa.eu/en/news-events/ecdc-and-ema-considerations-additional-and-booster-doses-covid-19-vaccines Google Scholar
    6. COVID-19 vaccine boosters. centers for disease control and prevention, 2022. Available: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html [Accessed 24 Aug 2022].Google Scholar
    7. Ecdc and EMA update recommendations on additional booster doses of COVID-19 vaccines. European centre for disease prevention and control, 2022. Available: https://www.ecdc.europa.eu/en/news-events/ecdc-and-ema-update-recommendations-additional-booster-doses-covid-19-vaccines [Accessed 24 Aug 2022].Google Scholar
    8. JCVI statement on COVID-19 vaccination of children aged 12 to 15 years: 3 September 2021. joint Committee on vaccination and immunisation. Available: https://www.gov.uk/government/publications/jcvi-statement-september-2021-covid-19-vaccination-of-children-aged-12-to-15-years/jcvi-statement-on-covid-19-vaccination-of-children-aged-12-to-15-years-3-september-2021 [Accessed 24 Aug 2022].Google Scholar
      2. John SD 
      . How low can you go? justified hesitancy and the ethics of childhood vaccination against COVID-19. J Med Ethics 2022.doi:10.1136/medethics-2021-108097 Google Scholar
    9. Single dose of COVID-19 vaccine to be offered to 12-15 year olds. Department of health and social care, 2021. Available: https://www.gov.gg/article/185637/Single-dose-of-COVID-19-vaccine-to-be-offered-to-12-15-year-olds [Accessed 24 Aug 2022].Google Scholar
    10. Vaccine mandates. Institute for government, 2022. Available: https://www.instituteforgovernment.org.uk/explainers/vaccine-mandates [Accessed 24 Aug 2022].Google Scholar
      2. Slifka AM , 
      3. Park B , 
      4. Gao L , et al 
      . Incidence of tetanus and diphtheria in relation to adult vaccination schedules. Clin Infect Dis 2021;72(2):285–92.doi:10.1093/cid/ciaa017 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32095828 PubMedGoogle Scholar
    11. Withdrawal of rotavirus vaccine recommendation. centers for disease control and prevention. morbidity and mortality weekly report. 1999;48(43):1007. Available: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a5.htm Google Scholar
    12. Johnson & Johnson’s Janssen COVID-19 Vaccine: Overview and Safety. Centers for Disease Control and Prevention. Available: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/janssen.html [Accessed 24 Aug 2022].Google Scholar
      2. Lee KMN , 
      3. Junkins EJ , 
      4. Luo C , et al 
      . Investigating trends in those who experience menstrual bleeding changes after SARS-CoV-2 vaccination. Sci Adv 2022;8(28).doi:10.1126/sciadv.abm7201 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35857495 PubMedGoogle Scholar
      2. Aksu SB , 
      3. Öztürk GZ 
      . A rare case of shingles after COVID-19 vaccine: is it a possible adverse effect? Clin Exp Vaccine Res 2021;10(2):198–201.doi:10.7774/cevr.2021.10.2.198 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34222134 PubMedGoogle Scholar
    13. COVID-19 vaccine effectiveness in adolescents aged 12–17 years and interim public health considerations for administration of a booster dose. European centre for disease prevention and control, 2022. Available: https://www.ecdc.europa.eu/en/publications-data/covid-19-vaccine-effectiveness-adolescents-and-interim-considerations-for-booster-dose [Accessed 24 Aug 2022].Google Scholar
      2. Vatti A , 
      3. Monsalve DM , 
      4. Pacheco Y , et al 
      . Original antigenic sin: a comprehensive review. J Autoimmun 2017;83:12–21.doi:10.1016/j.jaut.2017.04.008 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28479213 CrossRefPubMedGoogle Scholar
      2. Aaby P , 
      3. Benn CS , 
      4. Flanagan KL , et al 
      . The non-specific and sex-differential effects of vaccines. Nat Rev Immunol 2020;20(8):464–70.doi:10.1038/s41577-020-0338-x CrossRefPubMedGoogle Scholar
      2. Aaby P , 
      3. Netea MG , 
      4. Benn CS 
      . Beneficial non-specific effects of live vaccines against COVID-19 and other unrelated infections. Lancet Infect Dis 2022. doi:doi:10.1016/S1473-3099(22)00498-4. [Epub ahead of print: 26 Aug 2022].pmid:http://www.ncbi.nlm.nih.gov/pubmed/36037824 PubMedGoogle Scholar
      2. Attwell K , 
      3. C Navin M 
      . Childhood vaccination mandates: scope, sanctions, severity, selectivity, and salience. Milbank Q 2019;97(4):978–1014.doi:10.1111/1468-0009.12417 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31529546 PubMedGoogle Scholar
      2. Wertheimer A , 
      3. Miller FG 
      . Payment for research participation: a coercive offer? J Med Ethics 2008;34(5):389–92.doi:10.1136/jme.2007.021857 pmid:http://www.ncbi.nlm.nih.gov/pubmed/18448723 Abstract/FREE Full TextGoogle Scholar
      2. Fisher JA 
      . Expanding the frame of “voluntariness” in informed consent: structural coercion and the power of social and economic context. Kennedy Inst Ethics J 2013;23(4):355–79 http://muse.jhu.edu/journal/107 doi:10.1353/ken.2013.0018 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24552076 PubMedGoogle Scholar
      2. Bambery B , 
      3. Douglas T , 
      4. Selgelid MJ , et al 
      . Influenza vaccination strategies should target children. Public Health Ethics 2018;11(2):221–34.doi:10.1093/phe/phx021 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30135702 PubMedGoogle Scholar
      2. Gazit S , 
      3. Saciuk Y , 
      4. Perez G , et al 
      . Short term, relative effectiveness of four doses versus three doses of BNT162b2 vaccine in people aged 60 years and older in Israel: retrospective, test negative, case-control study. BMJ 2022;377:e071113.doi:10.1136/bmj-2022-071113 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35609888 Abstract/FREE Full TextGoogle Scholar
    14. SARS-CoV-2 variants of concern and variants under investigation in England technical briefing: update on hospitalisation and vaccine effectiveness for omicron VOC-21NOV-01 (B.1.1.529). UK health security agency, 2021. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1045619/Technical-Briefing-31-Dec-2021-Omicron_severity_update.pdf [Accessed 24 Aug 2022].Google Scholar
      2. Wilder-Smith A 
      . What is the vaccine effect on reducing transmission in the context of the SARS-CoV-2 delta variant? Lancet Infect Dis 2022;22(2):152–3.doi:10.1016/S1473-3099(21)00690-3 Google Scholar
      2. Holm S 
      . A general approach to compensation for losses incurred due to public health interventions in the infectious disease context. Monash Bioeth Rev 2020;38(S1):32–46.doi:10.1007/s40592-020-00104-2 Google Scholar
      2. Benn CS , 
      3. Fisker AB , 
      4. Rieckmann A , et al 
      . Vaccinology: time to change the paradigm? Lancet Infect Dis 2020;20(10):e274–83.doi:10.1016/S1473-3099(19)30742-X CrossRefPubMedGoogle Scholar
    15. Countermeasures injury compensation program (CICP). health resources and services administration. Available: https://www.hrsa.gov/cicp [Accessed 24 Aug 2022].Google Scholar
      1. Vaccine Injury Support Program
      . Government of Canada. Available: https://vaccineinjurysupport.ca/en [Accessed 24 Aug 2022].Google Scholar
      2. Gill JR , 
      3. Tashjian R , 
      4. Duncanson E 
      . Autopsy histopathologic cardiac findings in 2 adolescents following the second COVID-19 vaccine dose. Arch Pathol Lab Med 2022;146(8):925–9.doi:10.5858/arpa.2021-0435-SA CrossRefGoogle Scholar
      1. Countermeasures Injury Compensation Program (CICP)
      . Health resources and services administration. data on CICP. Available: https://www.hrsa.gov/cicp/cicp-data [Accessed 24 Aug 2022].Google Scholar
    16. Comirnaty and Pfizer-BioNTech COVID-19 vaccine. food and drug administration. Available: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/comirnaty-and-pfizer-biontech-covid-19-vaccine#comirnaty [Accessed 24 Aug 2022].Google Scholar
      2. Olivier M 
      . Emory restricts WiFi for students noncompliant with booster requirements, sees slight increase in COVID-19 cases. The Emory wheel, 2022. Available: https://emorywheel.com/emory-restricts-wifi-for-students-noncompliant-with-booster-requirements-sees-slight-increase-in-covid-19-cases/ Google Scholar
      2. Braganca D 
      . Stanford to international students: get the booster or face Deportation | opinion. Newsweek, 2022. Available: https://www.newsweek.com/stanford-international-students-get-booster-face-deportation-opinion-1693073 Google Scholar
      2. Godlee F 
      . What should we do about vaccine hesitancy? BMJ 2019;365.doi:10.1136/bmj.l4044 Google Scholar
      2. Bhargava I 
      . Some Western students confused why university mandated a 3rd COVID-19 shot after they’d paid tuition. CBC, 2022. Available: https://www.cbc.ca/news/canada/london/western-students-covid-mandates-1.6560239 [Accessed 24 Aug 2022].Google Scholar
      2. Regev-Yochay G , 
      3. Gonen T , 
      4. Gilboa M , et al 
      . Efficacy of a fourth dose of Covid-19 mRNA vaccine against omicron. N Engl J Med 2022;386(14):1377–80.doi:10.1056/NEJMc2202542 pmid:http://www.ncbi.nlm.nih.gov/pubmed/35297591 CrossRefPubMedGoogle Scholar
      2. Lipson SK , 
      3. Zhou S , 
      4. Abelson S , et al 
      . Trends in college student mental health and help-seeking by race/ethnicity: findings from the National healthy minds study, 2013–2021. J Affect Disord 2022;306(2):138–47.doi:10.1016/j.jad.2022.03.038 Google Scholar
      2. Selgelid MJ 
      . A moderate Pluralist approach to public health policy and ethics. Public Health Ethics 2009;2(2):195–205.doi:10.1093/phe/php018 CrossRefWeb of ScienceGoogle Scholar
      2. Mosby I 
      . Administering colonial science: nutrition research and human biomedical experimentation in Aboriginal communities and residential schools, 1942–1952. Histoire Soc 2013;46(91):145–72.doi:10.1353/his.2013.0015 Google Scholar
      2. Haidt J 
      . The righteous mind: why good people are divided by politics and religion. Vintage 2013.Google Scholar
    17. The Unintended Consequences of COVID-19 Vaccine Mandates: Why They May Cause More Harm than Good – YouTube. Available: https://www.youtube.com/watch?v=QjUskKTq_Qc [Accessed 30 Aug 2022].Google Scholar
      2. Gomez M , 
      3. Money L , 
      4. Rong-Gong LLA 
      . Schools chief pushes to delay student COVID vaccination mandate, 2022. Available: https://www.latimes.com/california/story/2022-04-28/l-a-schools-chief-seeks-delay-of-student-covid-vaccine-mandate [Accessed 3 Oct 2022].Google Scholar
      2. Segraves N 
      . DC extends deadlines for student COVID-19 vaccination, routine immunizations, 2022. Available: https://www.nbcwashington.com/news/local/dc-extends-deadlines-for-student-covid-19-vaccination-routine-immunizations/3142816/ [Accessed 30 Aug 2022].Google Scholar
    18. ABPD statement in support of COVID-19 vaccine mandates for all eligible Americans. Association of bioethics program directors, 2021. Available: https://www.bioethicsdirectors.net/wp-content/uploads/2021/09/ABPD-Statement-in-Support-of-COVID-19-Vaccine-Mandates_FINAL9.22.2021.pdf [Accessed 24 Aug 2022].Google Scholar
      2. Mach D , 
      3. Cole D 
      . Civil liberties and vaccine mandates: here’s our take. American Civil Liberties Union, 2021. Available: https://www.aclu.org/news/civil-liberties/civil-liberties-and-vaccine-mandates-heres-our-take [Accessed 24 Aug 2022].Google Scholar
      1. OHRC Policy statement on COVID-19 vaccine mandates and proof of vaccine certificates
      . Ontario human rights Commission, 2021. Available: https://www.ohrc.on.ca/en/news_centre/ohrc-policy-statement-covid-19-vaccine-mandates-and-proof-vaccine-certificates [Accessed 30 Aug 2022].Google Scholar
      2. Fraiman J , 
      3. Erviti J , 
      4. Jones M , et al 
      . Serious adverse events of special interest following mRNA COVID-19 vaccination in randomized trials in adults. Vaccine 2022;40(40):5798–805.doi:10.1016/j.vaccine.2022.08.036 CrossRefPubMedGoogle Scholar


    • 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.
    • Offit recommended that his own son not receive a booster dose due to concerns that benefits would not outweigh risks (see: https://www.theatlantic.com/health/archive/2022/01/should-teens-get-booster-omicron/621222/).
    • See also: https://www.fda.gov/safety/reporting-serious-problems-fda/what-serious-adverse-event (accessed 20 October 2022).
    •  Table 3e footnote h: Overall, 4/344 (1.2%) participants experienced five SAEs during a median follow-up of 5.7 months after booster dose (administered at least 6 months after a 50 μg (n=173) or 100 μg (n=171) two-dose primary series); the sponsor deemed these unrelated to mRNA-1273. Data on an equivalent primary series comparison group were not available at the time of the GRADE assessment.
    • Table 3e, footnotes (h), (i), (j): h. Overall, 4/344 (1.2%) participants experienced five SAEs during a median follow-up of 5.7 months after booster dose (administered at least 6 months after a 50 μg (n=173) or 100 μg (n=171) two-dose primary series); the sponsor deemed these unrelated to mRNA-1273. Data on an equivalent primary series comparison group were not available at the time of the GRADE assessment. i. Comparator group is 100 µg primary series recipients in the phase II randomised dose confirmation study. j. Participants’ ability to choose whether to receive a booster likely introduced selection bias (eg, those with adverse events or reactions with the primary series may have been less likely to choose a booster).

    by Max Lowen

    Trauma occurs inside us as a response to an overwhelming event, it is not the event itself. Trauma includes feelings of intense fear/terror, helplessness, loss of control and threat of annihilation.

    Traumatic reactions occur when action is of no avail, when neither resistance (fight) or escape (flight) is possible. We have a survival system built into our brain, sometimes called the reptilian brain, which responds to danger (or the threat of danger) by activating the sympathetic nervous system into fight or flight. If we can do either, the risk of trauma is lower. When no recourse is possible, an individual may go into a freeze response and dissociate from their body.

    Traumatic events are defined as “extraordinary” not because they occur rarely (unfortunately quite the contrary) but because they overwhelm and confront human beings with the extremities of helplessness and terror.

    The human system of self-defense becomes overwhelmed and disorganized, and the reactions persist in an altered and exaggerated state long after the actual danger is over. Traumatic memories get preserved in an abnormal state, set apart from ordinary consciousness. Normal memories get processed by the brain and then stored away. When we remember something, it is a recollection, somewhat faded or old. Traumatic memories are stored differently, not processed but stored raw along with the concurrent emotions, smells, sights, sounds and event. When the memory is activated, it is like a replay of what happened, as raw and terrifying as the original event. Almost like a video that gets replayed at the touch of a button. This is called a flashback. As an example, a war vet walks down the street and a car backfires. It triggers a traumatic memory from war and he reacts as if in a gun battle, screaming, diving to the ground, agitated and in that moment back in the past. Any attempt to talk to him will fail until his system comes back to baseline. The trauma of the past opens up and replays in the present.

    The body needs to be able to complete the action the trauma truncated. Animals do not become traumatized if they can complete the cycle. As an example, if a gazelle is chased by a cheetah and escapes, it will then shake until the trauma has passed through his body. The cycle is complete and the gazelle system returns to baseline. It holds no trauma after the event because it discharged the fear and was able to escape. Captivity, being helpless and trapped in the danger causes trauma.

    The Aftereffects of Trauma

    Symptoms of PTSD (Post Traumatic Stress Disorder) or trauma can be divided into three rough categories: hyperarousal, intrusion and constriction.

    Hyperarousal: The human system of self-preservation goes into permanent alert and state of hyperarousal. The traumatized person sleeps poorly, startles easily and reacts irritably to small provocations. No normal baseline exists anymore, the body is always on alert for danger, both in waking and in sleep. The traumatic events recondition the nervous system.

    Intrusion: The traumatic moment becomes encoded in an abnormal form of memory which breaks into ordinary consciousness spontaneously in the form of flashbacks during waking times and nightmares during sleep. Certain events can trigger the traumatic memories which then open up with all the vividness and emotional force of the original event.

    Constriction: what happens when a person is completely helpless and any form of resistance is futile? The helpless person escapes instead by altering their state of consciousness. The person becomes numb and feels like the events are not happening to her, like watching herself be abused from outside her body. It is like a hypnotic trance of sorts, and is a surrender of voluntary action and distortion of reality. The constriction of the field of consciousness produces amnesia of the event, it splits off from ordinary awareness. This is how the traumatic event becomes a repressed memory.

    To control their pervasive fear, traumatized people restrict their lives, they avoid going places or being in situations they fear will trigger them. Constrictive symptoms interfere with anticipation and planning for the future. They narrow and deplete the quality of life of the person. Intrusion clashes with constriction, flashbacks flood the person with intense overwhelming feelings, followed by amnesia or numbing.

    Trauma affects Attachment

    Traumatic events destroy the victim’s fundamental assumptions about the safety of the world, the positive value of the self and the meaningful order of creation.

    Basic trust sustains a person throughout the life cycle and forms the basis of all relationships and faith. Traumatized people feel utterly abandoned, alone, cast out of human or divine systems of care and protection. They have a sense of alienation and disconnection that pervades their relationships. Traumatized people feel they belong more to the dead than the living.

    Shame is a response to being helpless, to the violation of body integrity and the indignities suffered in the eyes of another person.

    Guilt happens as victims blame themselves, it is easier to believe it was us than to face the reality of utter helplessness.

    Trauma causes conflict between closeness and withdrawing from others, the trauma survivor has both a desperation for connection and is too terrified to sustain it. Terrified of being with people and terrified of being alone. Intense and contradictory feelings of need and fear.

    Complex/Developmental Trauma

    Trauma can be a single event or can occur in captivity, such as in a family, a religious cult, a prisoner (such as someone sex trafficked), a brothel or a concentration camp. The worst fear of any traumatized person is that the moment of horror will reoccur, and this fear is realized in victims of chronic abuse. Chronically traumatized people are continually hypervigilant, anxious and agitated. They have constant apprehension of imminent doom, a fear that something terrible is always about to happen. Chronically traumatized people no longer have any baseline state of physical calm or comfort.

    In victims of a single trauma, symptoms usually abate in days or months. In complex trauma, symptoms can last decades or longer in the form of flashbacks, nightmares and extreme reactions.

    People in captivity become adept at altered states of consciousness. They stop thinking of the future. Prolonged captivity disrupts all human relationships. The survivor oscillates between intense attachment and terrified withdrawal. Trauma survivors approach relationships as if they are life or death. There is no tolerance for mistakes from self or others. If things go awry, the survivor will withdraw, reinforcing the isolation of trauma. There is no trust, so every event feels like it is life or death.

    Adaptation to constant danger requires a constant state of alertness. Children in abusive situations become adept at sensing body language and energy. They develop extraordinary abilities to read others, because their survival depends on it.

    The abused child must find a way to form attachments to caregivers who are dangerous or negligent. The abused child must find a way to develop basic trust and safety with caregivers who are not trustworthy or safe. The abused child must develop a sense of self from others who are helpless, uncaring or cruel. The abused child must develop the capacity to regulate bodily functions when her or his body is at the disposal of others. The abused child must develop a capacity for self-soothing in an environment without solace. The abused child must develop a capacity for intimacy when relationships are destructive and aloof.

    To survive, the child must split off the abuse and pretend it didn’t happen, or she must blame herself. If she is bad, then her caretakers are good. If she is to blame, she retains hope she can change things. She searches for fault in her behavior to make sense of what happened. Children cannot tolerate seeing their caregivers as abusive, so they engage in psychological maneuvers to be able to carry on. Hence the abuse is either split off and put away, or the child blames herself and strives to be good or perfect in an effort to change things. Abused children develop premature competence, as well as amazing skills and abilities, because they have to do so to survive. If a child’s abilities are praised, they may feel like a fraud because of their dark secrets.

    Survivors have feelings of annihilation, dissociation and depersonalization, hence some self-mutilate in order to feel they exist. Some self -soothing methods survivors engage in are self-mutilation, purging and vomiting, compulsive sexual behavior, compulsive risk taking and drug and alcohol abuse.

    Stages of Recovery

    Safety, remembrance and mourning, reconnection with ordinary life and reconnection with self and higher consciousness are the stages of recovery. In remembrance, the survivor tells her story in depth and detail. The work of reconstruction transforms the traumatic memory so it can be integrated. Survivors need to remember and feel the emotions and bodily sensations. Sometimes survivors can tell the story, but are devoid of emotion, or have big emotions but no narrative for them. When all are together, felt and known integration occurs. Sometimes people wish to sever the parts of them that hold trauma, but that would be like amputating a leg because it hurts. The task is to know all the split off parts, especially the exiled parts that hold the traumatic memories. Our internal systems are complicated and clever, so to stay alive in the face of horrors too big to handle and terror that threatens to annihilate us, we maneuver and split off into parts. Some hold the traumatic memories and pain, and are buried deep in the being, away from conscious memory.

    Other parts develop who ensure the exiled parts stay out of awareness. Here people might use addictions or risk-taking behaviors to push the trauma down when it threatens to come to the surface. When the fragmentation is severe, it can lead to multiple personalities. There is a continuum of dissociation in trauma, with completely different personalities at the far end…but mainly severed parts each trying to work to keep the person alive and functioning. Even the worst behavior our parts engage in is really simply a way to keep going and survive. Someone who does drugs to numb the awareness of the trauma is trying to do what they can with memories that are too overwhelming. Of course, covering up the pain does not help in the long run, and causes more problems, but whatever a person has to do to survive is beneficial in that moment.

    Another layer of recovery involves healing the nervous system. Trauma is stored in the body as well as in the mind. With complex developmental trauma, the nervous system forms itself in an unnatural manner. Normally our nervous system alternates between arousal and relaxation. The sympathetic branch of the autonomic nervous system is responsible for gearing us up for action and attention, while the parasympathetic branch regulates our return to a baseline of calm balance and readiness. In survivors of complex trauma, the nervous system is dysregulated. The traumatized person is in a constant state of hyperarousal even when there is no danger. Hence even decades after leaving captivity, the trauma survivor lives in a state of fear and apprehension, never being able to relax and enjoy the safe present moment they may be in. Techniques such as deep breathing, body-oriented therapies and those that regulate the nervous system are needed to address the physical sequalae of trauma. Martial arts, dance and yoga are physical practices that can be very healing and help with dissociation and reconnection.

    At some point, after remembering, mourning must occur. Helplessness and isolation are the core of trauma. Empowerment and reconnection are core experiences of recovery. The survivor must reconnect to all the fragmented parts of the self, reconnect to others and restore the connection to a higher self or higher power.

    Empowerment can be learning to fight, for example taking up self-defense, boxing or martial arts. During the traumatic event the person could not fight or flee, so learning to fight and practicing can be very empowering and allow the body to do what it could not in the past.

    Speaking out and exposing these horrors is using the traumatic experience for the greater good and regaining one’s voice. Helping others with trauma can also be empowering and a form of healing. Surviving, healing and living free from trauma is the best way to conquer the past.

    Trauma is healable even if the healing process can be difficult. The freedom that comes internally from having the courage to heal is far superior to living a restricted life in constant fear and avoidance of reigniting the trauma. We as a human race have all experienced both individual and collective trauma to one degree or another. It is our responsibility to heal ourselves and each other so we can create a reality where all life is nurtured, protected and valued.


  • Homemade Weed Killer Recipes

    by Veronica Shaughnessy, Horticulture Professional

    People with green thumbs are united in their hatred for weeds and give these rather undesired visitors a collective thumbs-down. Weeds are essentially unwanted plant growths that crop up out of place where they are not sown intentionally.

    Despite your best efforts to keep weeds at bay, these pesky, persistent, and pernicious plants grow among purposefully planted vegetable patches and flowerbeds as well as garden pathways, waste areas, pots, and lawns.

    As they grow faster than native plants and successfully compete for available soil nutrients, water, sunlight, and space, they can impact the growth of your plants and figure as one of the major threats to any garden setting.[1]

    Of all the 250,000 species of plants known to man, only 3 percent or 80,000 possess the characteristics that can qualify them as weeds.


    While these rogue elements may serve certain interests such as providing organic matter, nectar for bees, and fodder for wildlife and stabilizing the soil, their demerits would still outweigh their merits in the eyes of any horticulture enthusiast.


    What are the Key Characteristics of Weeds?

    It’s extremely hard to tell weeds and regular crop plants apart as far as size, form, and morphological and physiological features are concerned.

    However, there are certain characteristics specific to weeds that account for their reputation as enemies of crops.[1]

    DIY weed killer
    • Unlike most plants, weeds are quite resilient and can survive in even the most adverse conditions.
    • These unwanted plants sprout just about anywhere and can be detrimental to other plants and poisonous for some grazing animals in the estate.
    • Some weeds spread more rampantly than others. For instance, weeds such as doob can ravage a field by speedy vegetative reproduction even under adverse conditions.
    • Some weed species can regrow from root and stem fragments left behind in the soil, making them almost impossible to get rid of by hand.
    • Weeds are strong competitors and usually tend to have an upper hand over planted crops. They have the ability to outcompete most intentionally planted horticultural crops. Weeds sprout earlier and spread faster, hogging sunlight, moisture, and soil nutrients. If left unchecked, weeds can strangle the growth of other plants.
    • They are usually well endowed with seeds, which have a high germination rate (this means many of the seeds produced will sprout, even in adverse conditions), that sprout earlier and grow faster than most horticultural crops. Given their formidable reproductive capacity, it can be quite difficult to control and sometimes even impossible to eradicate some weeds completely.
    • The weed seeds remain viable despite being buried deep into the soil. They can also lie dormant for a long time. These seeds germinate and the sapling shoots through the layers of soil into a full-bloom weed.
    • These undesirable plants may exhibit special features such as hooks, prickly spines, wings, and sticky hair-like growths, which allow for their easy dissemination across long distance and difficult fruit removal as an eradication method.

    What Makes Weed a Nuisance?

    Despite diligent trimming and pruning, even the most well-kept garden is not safe from a potential weed attack. Not only do they put a damper on your concerted garden grooming efforts, but weeds can also damage your carefully planted and often expensive plants.

    Similarly, they are a menace for agricultural plantations. Weeds can contaminate harvested crops just as easily as they can inhibit the growth of regular plants. Weeds can invade via the wind, via underground roots or tubers, and even via store-bought soil mix.


    Here are the other nuisances of weeds:

    • Not only do weeds compete with your plants for nutrients in the soil, but they also compete for sunlight and water.
    • Weeds can also jeopardize the growth of your precious plantations as they are often carriers of disease that can easily be transmitted to other plants via insects, wind, and pruners.
    • Ridding a field of weeds requires extensive labor and tillage operations, both of which greatly increase the overall cost of cultivation and simultaneously reduce the margin of net profit.
      • Even in a home garden, weeds can cost the gardener enjoyment, as managing them can take up so much time.
    • Some weeds even contain certain harmful phytotoxins that give off secretions that negatively impact the growth of many crop plants.
    • Weeds can serve as reservoirs for various insects, pests, and diseases that can wreak havoc on your carefully curated plantation. Moreover, the weed themselves can prey upon other relatively fragile plants as alternate hosts.
    • Weeds can bring down the overall quality of field harvest as well, as the undesirable weed seeds can get easily mixed up with the main produce.
    • Weeds can cut off air passage between cultivated plants and lock too much moisture into the soil, triggering the spread of disease.
    • Weeds adversely impact the irrigation efficiency by obstructing proper drainage, curbing the flow of water in irrigation and field channels. As a result, you may incur additional losses on account of unnecessary seepage and overflowing.
    • Weeds accelerate the breakdown of farm implements and can render them useless unless they are properly sharpened, mended, or maintained.
    • Agricultural lands that are perennially infested with weeds such as kans tend to fetch less price in the real estate market as they call for added expenditure on labor and machinery.

    Homemade Weed Killers

    Even in the best of plots, weeds will grow, and to get rid of these unwelcome visitors, the market is flooded with chemical options. However, using chemical-enriched solutions often affects the growth of your valuable plants and even causes damage to the soil in the long run.

    Pulling weeds by hand is always the most reliable solution but not always a practical one. So, to keep your garden free from weeds, you can look for natural options, which are generally less harmful to the environment than chemical ones.

    To that end, you can whip up a nontoxic weed killer solution by blending a few natural ingredients that are often readily available at your home.

    You would be surprised to know what something as commonplace as white vinegar, lemon juice, liquid dish soap, and Epsom salt can do to weed out your weedy troubles.


    The acidity of the vinegar and lemon juice works to adjust water and soil pH and sucks out moisture from weeds or causes foliar burn, eventually leading to their death.

    This beneficial trait draws legitimacy from a study that highlighted the efficacy of an acid-based formula containing NaCl, citric acid, and wood vinegar in controlling broadleaf weeds through contact poisoning.

    However, the said herbicidal mix was found to be rather ineffective against grasses.[2] This is often true of weed remedies, chemical or otherwise. You will find that mixes effective against dicots (plants with netted venation) are often not effective against monocots (plants with parallel venation).

    Even salt is excellent at dehydrating the weeds, eventually causing their death.[2] It not only kills existing weeds but also prevents the growth of new ones in the same area.

    An experimental study was conducted to examine the effectiveness of salt for weed management in jhum paddy in mid-hill conditions in the Eastern Himalayas. The researchers found that application of salt at the rate of 120 kg ha-1 resulted in significantly higher grain yield and higher weed control efficiency than three hand weeding.[3]


    Additionally, the liquid dish soap will work as a surfactant, which means it will help reduce the surface tension that can cause the weed-killing concoction to bead on the leaves instead of being absorbed by the plant. [4][5]

    Here are 3 homemade weed killer recipes that are safe and effective.

    Recipe #1: Vinegar, Salt, and Liquid Dish Soap Homemade Weed Killer

    Recipe #2: Salt and Water Homemade Weed Killer

    Recipe #3: Lemon Juice and Dish Soap Homemade Weed Killer

    Recipe #1: Vinegar, Salt, and Liquid Dish Soap Homemade Weed Killer

    Things you’ll need:

    homemade white vinegar and dish soap weed killer
    • White vinegar – 1 gallon
    • Liquid dish soap – 2 tablespoons
    • Epsom salt – 1 cup


    1. Take a pitcher and add 1 gallon of white vinegar into it.
    2. Add 2 tablespoons of liquid dish soap to it.
    3. Add 1 cup of Epsom salt.
    4. Stir well to blend the three ingredients.
    5. Transfer the solution into a spray bottle, using a small funnel.
    6. This homemade weed killer using vinegar, liquid dish soap, and Epsom salt is ready to use.

    Recipe #2: Salt and Water Homemade Weed Killer

    Things you’ll need:

    salt and water weed killer recipe
    • Salt – ½ cup
    • Water – 1 cup


    1. In a bowl, put ½ cup of table salt.
    2. Add 1 cup of lukewarm water.
    3. Stir properly until the salt dissolves completely.
    4. Transfer the saline solution in a spray bottle, using a small funnel.
    5. This salt and water homemade weed killer for spot treating weeds in your garden is ready.

    Recipe #3: Lemon Juice and Dish Soap Homemade Weed Killer

    Things you’ll need:

    • Lemon – ½
    • Liquid dish soap – 1½ tablespoons
    • Water – 1 cup in a spray bottle


    1. Pour 1 cup of water in a spray bottle.
    2. Add 1½ tablespoons of liquid dish soap in a spray bottle.
    3. Squeeze the juice of half a lemon into the bottle.
    4. Put the nozzle on the spray bottle and give it a nice shake to help the ingredients mix properly.
    5. This lemon juice and liquid dish soap homemade weed killer is ready to keep your garden free from weeds.

    How to Use the DIY Homemade Weed Killers

    You can use any of the above-mentioned DIY homemade week killer recipes to keep your garden free from weeds.

    These remedies fare best when used under bright and sunny weather conditions. The sun always assists in dehydrating or burning of plant tissues. Check the weather forecast to make sure that the day you have chosen will be a sunny one and there will be no rain for a couple of days.

    vinegar-salt-dish soap weed killer

    All you need to do is shake the bottle properly and then spray any of the homemade solutions on the leaves and stems of the weeds, but not the soil or the crops you desire to keep.

    A single spray will help dry out the weeds in a week’s time. Repeat the process if remnants of the weed continue to persist.

    So long as the weed is not completely eliminated, there’s always the risk of regrowth. After pulling some of the larger weeds, the spray can be used to kill off underground growth by simply spraying the remaining stump or root.

    Additional Tips

    • You need to spray the homemade weed killers on the leaves and stems of the weeds only.
    • Avoid spraying the solution on the soil as it can kill your valuable plants along with the weeds.
    • Once done, you can store the leftover homemade weed killers in a dark and cool place and use them as needed.


    1. Ligenfelter DD. Introduction to Weeds: What are Weeds and Why do we Care? Penn State Extension. https://extension.psu.edu/introduction-to-weeds-what-are-weeds-and-why-do-we-care. Published December 9, 2009.
    2. Rahayuningsih S, Supriadi S. HERBICIDAL EFFICACY OF ACETIC ACID AND CITRIC ACID BASE ON BROAD LEAF WEEDS OF MEDICINAL CROPS FIELDS. Buletin Penelitian Tanaman Rempah dan Obat. http://ejurnal.litbang.pertanian.go.id/index.php/bultro/article/view/3117. Published 2014.
    3. S RS, Naro K, Kapila S. Weed management through salt application: An indigenous method from shifting cultivation areas, Eastern Himalaya, India. NISCAIR Online Periodicals Repository. http://nopr.niscair.res.in/handle/123456789/13870. Published April 1, 2012.
    4. Tanveer A, Ayub M, Ali A, Ahmad R. Phytotoxic Effect of Herbicides with and without Surfactant on Weed Growth and Yield of Wheat. Journal of Arts and Social Sciences [JASS]. https://journals.squ.edu.om/index.php/jams/article/view/552. Published 1999.
    5. Jansen LL, Gentner WA, Shaw WC. Effects of Surfactants on the Herbicidal Activity of Several Herbicides in Aqueous Spray Systems | Weeds. Cambridge Core. https://www.cambridge.org/core/journals/weeds/article/effects-of-surfactants-on-the-herbicidal-activity-of-several-herbicides-in-aqueous-spray-systems/007F19E0898088ED4A41C733395417FD. Published June 12, 2017.
  • How to Make Your Own Homemade Pain Balm

    by Top10HomeRemedies Team

     January 30, 2019


    Pain disrupts our daily life and messes with our routine. Sore muscles and achy joints can be hard to bear, especially if it’s a chronic problem.

    Such ailments are often caused by excessive activity, staying in one position for too long, exhaustive working hours, heavy lifting, improper posture or simply aging. Pain can also be a symptom of many underlying conditions, such as arthritis or fibromyalgia.

    Pain medications can only last so long, and they are also pretty expensive. In addition, they may have side effects that can further wreak havoc in your daily life. These side effects may include nausea, a rash, stomach upset, heartburn and fatigue. When taken in high doses, some medications can also cause liver damage and increase the risk of heart attack.

    how to make homemade pain balm


    This DIY pain balm is an economical option that will help alleviate pain in your joints and muscles as well as reduce inflammation. The various ingredients used in this recipe lend different properties to the balm.

    Here are the benefits of a few of the ingredients:

    • Camphor has anti-inflammatory properties that help relieve pain and inflammation.
    • Peppermint oil has cooling properties, which relieves sore muscles and has a calming effect on the body.
    • Arnica oil helps reduce inflammation, and its analgesic properties help numb the pain. It is used to treat pains, bruises, sprains and other ailments.
    • Clove oil also has analgesic qualities for pain relief. It also relaxes sore muscles.


    How to Make Homemade Pain Balm

    Things you’ll need:

    how to make homemade pain balm
    • Extra-virgin coconut oil – ¼ cup
    • Grated beeswax – 2 tablespoons (or 1 ounce)
    • Camphor – 1 tablespoon or 10 to 12 balls
    • Peppermint essential oil – 9 drops
    • Arnica essential oil – 7 drops
    • Clove essential oil – 5 drops
    • Sterile storage container


    1. Measure out ¼ cup of extra-virgin coconut oil and put it in a bowl.

    add coconut oil for pain balm


    2. Add 2 tablespoons (or 1 ounce) of pure grated beeswax to it.

    add beeswax for pain balm

    3. Heat it in the microwave for 30 seconds to 1 minute, until the ingredients are completely melted.

    heat mixture in microwave

    4. Add 10 to 12 camphor balls to the mixture, and microwave for 20 seconds or until the balls dissolve completely.

    add camphor balls to make pain balm

    5. Add 9 drops of peppermint, 7 drops of arnica and 5 drops of clove essential oils.

    add peppermint oil for homemade pain balm

    6. Mix the contents thoroughly using a wooden stick. This mixture can stubbornly adhere to metal utensils.

    stir the mixture


    7. Transfer it to a sterile storage container.

    transfer in a storage container

    8. Leave it for a few hours at room temperature to cool down.

    allow it to cool

    How to use your homemade pain balm

    homemade DIY pain balm recipe
    1. Scoop up some of the balm with your finger.
    2. Gently apply it to the affected area, massaging in a circular motion for 5 minutes.
    3. There is no need to cover the area. The balm can be left on and does not to be rinsed off.


    While side effects are rare from a natural pain balm, it always helps to ensure that you have taken proper precautions.

    • Make sure you are not allergic to any of the ingredients.
    • Do not apply the balm on open wounds, or nose, or eyes.
    • It is for external use only. Do not swallow it.
    • If your skin feels irritated after application, wipe off the balm immediately.

    Tips and Alternatives


    • If you do not have all of the above mentioned oils, try suitable substitutes like eucalyptus oil, rosemary oil, cinnamon oil, or chamomile oil.
    • You can use a double boiler instead of a microwave to melt the ingredients. If you don’t have one, you can arrange a makeshift double boiler by simmering a few inches of water in a saucepan and then placing a ceramic or glass bowl on top of the saucepan. The bottom of the bowl should not touch the saucepan. Keep adding water to replace any lost to evaporation.
    • Beeswax is available in a variety of forms like pellets, blocks, beads and pastilles. You can use any form for this recipe.
    • Instead of a stick, you can use a wooden paint stirrer or a wooden chopstick to mix the ingredients.
    • If you do not have a tin container, you can use a sterile glass jar with a lid. To sterilize the jar, wash it thoroughly with hot water and soap. Next, place it upright in a deep pot and fill the pot with water until it covers the jar by 1 inch. Boil the water for 10 minutes. Then, use tongs to remove the jar from the pot and place it on a paper towel to dry.
    • Make sure to keep the balm away from direct sunlight.
  • DIY Homemade Activated Charcoal Toothpaste for Teeth Whitening

    by Top10HomeRemedies Team

     January 30, 2019


    Most of us start our day by brushing our teeth, and many have strong opinions about which toothpaste they prefer.

    Some prefer plain white toothpaste, some like mint-flavored and some like bubblegum-flavored. There are numerous choices in the market.

    But are you sure that the toothpaste you are using is safe? You may be shocked to learn that most store-bought toothpastes contain a number of harmful ingredients and can cause more harm than good to your teeth and overall health.

    Some of the toxic ingredients used in commercial toothpastes are triclosan, sodium lauryl sulfate, propylene glycol, microbeads and diethanolamine, to name a few. Also, commercial toothpastes are flavored with artificial sweeteners like aspartame.


    So, how do you keep your teeth clean if the commercial toothpaste you bought is not safe?

    Well, a healthy diet and oil pulling can go a long way in maintaining your oral health. And for toothpaste, you can make your own at home. It is simple and inexpensive, and you’ll know you’re using safe ingredients.

    homemade activated charcoal toothpaste

    For instance, you can make a natural whitening toothpaste with just three ingredients – activated charcoal, extra-virgin coconut oil and eggshell powder. This homemade toothpaste is far less abrasive than commercial whitening toothpastes and will not harm your teeth or gums.

    Activated charcoal helps whiten your teeth by reducing stains and plaque on your teeth. In fact, the microporous charcoal works by binding to compounds that stain teeth, including coffee and red wine. Also, it improves the pH balance in your mouth and helps fight bad breath.

    Another ingredient in this homemade toothpaste is eggshell powder. Being a rich source of calcium, eggshell powder helps strengthen your teeth. It even remineralizes your teeth over time.


    The last ingredient in this recipe is extra-virgin coconut oil, which is extremely beneficial for your oral health. It helps maintain good oral and dental hygiene and plays a key role in preventing bad breath, tooth decay, cavities and gingivitis. It also reduces tooth sensitivity.

    It does so by attacking the harmful bacteria in your mouth, which in turn decreases plaque formation, the key reason behind several oral problems. It also helps whiten and brighten your teeth.

    Caution: If you have caps on your teeth, consult your dentist before using this homemade activated charcoal toothpaste.


    How to Make DIY Homemade Activated Charcoal Toothpaste for Teeth Whitening

    Things you’ll need:

    DIY homemade activated charcoal toothpaste to whiten your teeth


    • Activated charcoal – ½ teaspoon
    • Eggshell powder – 1 tablespoon
    • Extra-virgin coconut oil, melted – 1 tablespoon


    1. Put ½ teaspoon of activated charcoal in a bowl.

    step 1 take half tsp activated charcoal

    2. Add 1 tablespoon of eggshell powder.

    step 2 add 1 tbsp eggshell powder

    3. Then add 1 tablespoon of melted, extra-virgin coconut oil.

    step 3 add 1 tbsp coconut oil

    4. Mix the ingredients with a nonmetallic spatula or spoon until you get a smooth paste-like consistency.

    mix ingredients for DIY activated charcoal toothpaste

    5. Your homemade toothpaste is ready to use. Transfer it to an airtight container.

    transfer activated charcoal toothpaste in airtight container


    How to use your homemade activated charcoal toothpaste

    activated charcoal toothpaste homemade
    1. Put a small amount of your homemade toothpaste on your toothbrush, using a small spatula or spoon.
    2. Brush your teeth as usual, giving equal attention to the front as well as the back of your teeth.
    3. Once you’re done brushing, rinse your mouth thoroughly with lukewarm water.
    4. You can use this toothpaste daily.

    Additional Tips

    • You can use pH strips to test the acidity of your homemade toothpaste. It should have a pH of 7 (neutral) or higher, which means this toothpaste is safe for use.
    • This homemade toothpaste does not contain any baking soda, meaning it’s not abrasive on your teeth.
    • You can buy activated charcoal in tablet, capsule, or powder form. If you buy the capsules, all you have to do is open them up. If using tablets, you can smash them into a powder form.
    • You can make the eggshell powder at home. For the recipe, check this page.
    • You can also add a little Himalayan salt to the toothpaste. It will help kill oral bacteria and reduce the risk of gum disease.
    • As this toothpaste has a slight grainy texture, it helps break up the biofilm of various substances to keep your teeth stain-free.
    • You can store the toothpaste in the medicine cabinet. There is no need to refrigerate it.
    • The toothpaste will last for several months.
    • If it begins to dry out, add a bit more melted, extra-virgin coconut oil and mix well before use.