Discussion

The results of our study show that public interest in myocarditis was low during the initial phase of the COVID-19 pandemic despite a relatively high number of myocarditis cases related to COVID-19; however, interest spiked during the early stages of the SARS-CoV-2 vaccine rollout and remained high through 2021. This was likely due to the media sensationalization of myocarditis following the emergency use authorization (EUA) and uptake of the SARS-CoV-2 vaccines when the ratio of events to vaccines given was extremely low. While the EUA was one of the first times a vaccine had received this designation, mRNA vaccines are not new. Functional mRNA has been successfully incorporated into human cells since 1978. ^{Reference Ostro, Giacomoni and Lavelle19} Over time, the development of mRNA and its use in vaccines has gradually progressed. ^{Reference Dolgin20}

In July 2020, before the vaccines were approved by the FDA for adults, ²¹ a team of data analysts looked at over 2 million tweets in the United States and United Kingdom to analyze the general public’s opinion. From these data, 10% of those who were hesitant about taking the vaccines stated they believed the development was “rushed.” ^{Reference Ray22} Furthermore, studies published soon after the vaccine rollout showed risks of developing myocarditis following SARS-CoV-2 vaccine uptake versus natural infection are 0.001% and 0.15%, respectively. ^{Reference Boehmer, Kompaniyets and Lavery3} Although the SARS-CoV-2 vaccines have proven to be efficacious in preventing COVID-19, they also are effective at preventing severe disease outcomes. ^{Reference Tregoning, Flight and Higham23} Therefore, the benefits of the SARS-CoV-2 vaccine significantly outweigh the risks of vaccine uptake and COVID-19. Despite these published benefits, RSI in myocarditis following vaccine rollout was disproportionate to the actual cases of vaccine-induced myocarditis. Thus, SARS-CoV-2 vaccine hesitancy is a major barrier to halting the pandemic.

Hesitancy has remained prevalent for various reasons, ^{Reference Troiano and Nardi24} starting with the initial lack of factual information regarding the origin of the virus and conspiracy theories circulating on the Internet, ^{Reference Islam, Kamal and Kabir25} which likely contributed to the public’s skewed interest toward vaccines and interest in myocarditis as our data suggests. Additionally, hesitancy has the ability to decrease health-care coverage while encouraging infectious disease outbreaks. ^{Reference Kennedy26} For example, the eradication of poliomyelitis faced a similar situation in 2004 when misleading information and public misperception regarding the polio vaccine led to a reemergence of polio in 13 countries where it had previously been eradicated. ^{Reference Aylward and Heymann27}

The sensationalization of myocarditis by media sources and the spread of misleading information has developed another sort of pandemic called an “infodemic.” ²⁸ This “infodemic” is responsible for the dissemination of false claims regarding SARS-CoV-2 vaccines that are easily spread through the use of social media, which saw a global 20-80% increase in usage during the pandemic. ^{Reference Naeem, Bhatti and Khan29} Additionally, the probability for an individual to believe misleading information may be a result of their health literacy and perceived risk ^{Reference Islam, Kamal and Kabir25} leading to increased SARS-CoV-2 vaccine hesitancy. ^{Reference Freeman, Waite and Rosebrock30}

Thus, improving health literacy skills can empower communities to overcome health inequity while strengthening community resilience toward infectious diseases such as COVID-19. ^{Reference Spring31} One way to accomplish this would be to increase surveillance and add disclaimers to posts shared on social media platforms and provide links to access to factual information, while also regulating or flagging sites where fake news is being distributed. ^{Reference Waszak, Kasprzycka-Waszak and Kubanek32} Several methods to combat the spread of misinformation have been mentioned in the literature such as using artificial intelligence to flag misinformation while providing guidelines or checklists, created by behavioral and science researchers, to help the public discern factual information ^{Reference Bin Naeem and Kamel Boulos33} Furthermore, evidence-based strategies to increase media and information literacy such as the “MIL CLICKS” initiative ³⁴ will enable the public to determine the validity of a claim to promote a more health literate society.