Last reviewed: February 22, 2022
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The following is a curated review of key information and literature about this topic. It is not comprehensive of all data related to this subject.
Overview
In addition to common adverse effects such as injection site pain, fatigue and headache, several more serious safety signals have been identified in relation to COVID-19 vaccination. Here, we review key evidence and clinical recommendations related to these rarer presentations. For more information about common side effects, refer to our mRNA and viral vector COVID-19 vaccine pages.
Myocarditis
Myopericarditis (inflammation of the cardiac lining and/or muscle) is a known, rare complication of vaccination that was best recognized in the pre-COVID-19 era following immunization against smallpox (Halsell, June 2003; Su, December 2020). Mechanisms underlying vaccine-associated myopericarditis are uncertain, but favored to represent non-allergic, immune-mediated effects in the setting of post-vaccination inflammatory milieu including possible antibody cross-recognition of cardiac tissue antigens (“molecular mimicry”) (Bozkurt, July 2021).
Although not noted during the landmark clinical trials of COVID-19 vaccines, myopericarditis temporally related to mRNA vaccination (Pfizer BioNTech 162b2 or Moderna mRNA-1273) has become better documented in the post-authorization phase. Specifically, there is an association between COVID-19 mRNA vaccination and higher relative rates of myopericarditis, particularly in younger males after the second vaccine dose. Absolute case numbers, however, are very low and predominately characterized by a short, self-limited syndrome. It is important to assess these rare adverse effects in the context of both the serious morbidity associated with COVID-19 itself, and significant benefits afforded by COVID-19 vaccination.
Clinical Presentation
A typical clinical presentation of vaccine-associated myopericarditis consists of chest pain and/or dyspnea beginning 1-5 days after administration of a vaccine dose, particularly the second of the two-dose mRNA series. Mild fever has been reported in several cases (Marshall, June 2021; Mevorach, October 2021), though molecular testing for acute SARS-CoV-2 infection is uniformly negative.
This syndrome is most frequently observed in younger adult males (see Incidence and Epidemiology). Several early series described a total of 20 males (85% <30 years of age) with similar symptomatology predominately after Pfizer vaccination who presented with elevated inflammatory markers (e.g., c-reactive protein) and moderately elevated troponin levels (Marshall, June 2021; Rosner, June 2021; Abu Mouch, June 2021). A single larger series of 23 male U.S. military personnel (median age 25) described a very similar syndrome occurring 1-4 days following a second dose of mRNA vaccination; two thirds had received the Moderna vaccine (Montgomery, June 2021).
Cardiac evaluation of myopericarditis cases has most commonly identified nonspecific electrocardiographic abnormalities, particularly S-T segment or T wave changes. Cardiac function may be normal by echocardiography, especially in younger patients and those with isolated pericarditis, though there have been several reports of mild to moderately depressed left ventricular ejection fraction (Montgomery, June 2021) (see Outcomes). Cardiac MRI, if performed, frequently shows evidence of myopericarditis such as patchy late gadolinium enhancement. Management is conservative, with therapy primarily consisting of non-steroidal anti-inflammatory medications, with administration of intravenous immune globulin (IVIG) and/or corticosteroids for select cases.
Outcomes
The characteristic clinical course of vaccine-associated myopericarditis includes brief hospitalization and significant symptom improvement occurring within a week of onset, without need for higher-level care or readmission. The largest published myopericarditis series utilized claims data and was adjudicated by clinical experts in Israel, identifying 136 definite or probable cases temporally related to vaccination among >5 million Pfizer vaccinees (Mevorach, October 2021). The majority of cases (95%) were considered mild based on quick resolution of symptoms and lab abnormalities, with short hospital stay. Similar findings were described in a U.S. health system study of 2.4 million vaccinees, where 15 total cases of myopericarditis were diagnosed (all in men <32 years of age), of whom 100% required hospital stays ≤3 days.
The Mevorach et al. national series did identify seven total cases of severe cardiac dysfunction temporally related to vaccination, including a single case of fatal myocarditis in a 22-year-old male among 358,511 vaccinees <25 years of age. Two additional severe presentations of myocarditis have been described in middle-aged adults 1-2 weeks after mRNA vaccination, characterized by depression of left ventricular function and shock, with one death (Verma, September 2021). Although myocarditis was diagnosed by biopsy in these latter two cases, causal relation to vaccination was not definitively established.
Epidemiology & Incidence Estimates
Population and health system-level studies have confirmed a consistent signal of increased relative incidence of myocarditis after vaccination, approximately 2-3-fold higher than unvaccinated control populations (Barda, September 2021; Mevorach, October 2021; Simone, October 2021). Absolute observed case numbers, however, remain very low, amounting to 5-30 excess myocarditis cases per million vaccine doses in the general population, with zero expected attributable deaths given mild clinical course.
Much benefit/risk focus has centered on adolescent and young adult males given higher relative incidence of vaccine-associated myopericarditis in this group. Adjudicated CDC review of VAERS data (passive reporting) detected highest cases rates in males ages 16-17, though this still remained <75 cases per million vaccinees (i.e., ~1/14,000 vaccinees) (Rosenblum slides, August 2021 [PDF]). An Israeli series found about 2-fold higher incidence of myopericarditis (~1/6636) among boys ages 16-19 years than in the U.S. series after two-dose Pfizer vaccination (Mevorach, October 2021). In both analyses, myocarditis incidence was 10-fold lower in female versus male adolescents, with observed case rates of ≤1/100,000 in young female vaccinees.
Of emerging interest is potential higher incidence of myopericarditis among recipients of the Moderna versus the Pfizer vaccine. For example, in unadjusted analysis, a Canadian health ministry detected a 6-fold higher rate among male Moderna vaccinees ages 18-24 after the second vaccination (47 cases, rate ~1/3,500) as compared Pfizer vaccinees (26 cases, ~1/23,000) (Public Health Ontario, October 2021 [PDF]). Several Nordic countries have considered restricting Moderna vaccination in younger males (Paterlini, October 2021), though other European countries continue to strongly endorse the benefits of mRNA vaccination in young adults (Haaf, October 2021). Ongoing surveillance and review of trials data is continuing in the U.S.
In contrast to the mRNA vaccines, myopericarditis following the single-dose Janssen (J&J) Ad26.COV2.S vaccine may be less common, though data are limited given fewer total administered doses and lack of authorization for the potential higher-risk group of children <18 years of age. A large multi-hospital retrospective study found zero cases of myocarditis and only two cases of pericarditis among >60,000 J&J vaccinees (Diaz, August 2021). In contrast, several case reports have described myocarditis of varying severity after J&J vaccination, including two critical cases temporally related to vaccination in elderly adults with significant comorbidities (Janssen, October 2021)
Risk versus Benefit of Vaccination in Younger Populations
Although there is a clear association between mRNA vaccination and the uncommon complication of myopericarditis, the benefits of vaccination in younger populations are significant. For example, in CDC analysis, for every million mRNA vaccine doses in males ages 12-19 years, ~40 cases of myocarditis would be expected (with zero deaths) whereas these vaccines would prevent 11,000 cases of COVID-19, including 650 hospitalizations, 138 ICU admissions, and six deaths (Gargano, July 2021). Additional national-level analyses in the U.S. support the protective benefits of vaccination, indicating that even in the context of the delta variant, hospitalization rates remain 10-fold lower among vaccinated versus unvaccinated children and adolescents (Delahoy, September 2021).
In addition to framing vaccine-associated myopericarditis risk versus that of a control, unvaccinated population, it is important to consider cardiac complications due to COVID-19 itself, that may be prevented through vaccination. CDC review of hospital claims data noted a >40% increase in myocarditis diagnoses in 2020 versus 2019 (pre-pandemic), with cases peaking along with COVID-19 waves. Overall myocarditis incidence was 0.15% in patients with COVID-19 (i.e., 1/667 infections) in contrast to <0.01% in those without COVID-19 (i.e., <1/10,000 persons). COVID-19 was associated with an overall 16-fold higher relative risk of myocarditis, including >30-fold higher risk for children <16 years of age (Boehmer, September 2021). The described incidence of myocarditis associated with COVID-19 in children is 10-15-fold higher than the reported case rates of myopericarditis after mRNA vaccination in adolescents (see Epidemiology & Incidence Estimates).