Bhattacharya-Kulldorff Joint Declaration — Norris v. Stanley

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EXHIBIT A 
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Joint Declaration of Dr. Jayanta Bhattacharya and Dr. Martin Kulldoff  
We, Drs. Jayanta (“Jay”) Bhattacharya and Martin Kulldorff provide the following Joint 
Declaration and hereby declare under penalty of perjury under the laws of the United 
States of America that the foregoing is true and correct: 
Background 
 
1. 
Dr. Jay Bhattacharya is a Professor of Medicine at Stanford University and a 
research associate at the National Bureau of Economic Research. He is also Director of Stanford’s 
Center for Demography and Economics of Health and Aging. He holds an M.D. and Ph.D. from 
Stanford University. He has published 152 scholarly articles in peer-reviewed journals in the fields 
of medicine, economics, health policy, epidemiology, statistics, law, and public health, among 
others. His research has been cited in the peer-reviewed scientific literature more than 11,000 
times. 
2. 
Dr. Martin Kulldorff is a Professor of Medicine at Harvard Medical School, and he 
is a biostatistician and epidemiologist at Brigham and Women’s Hospital. He holds a Ph.D. from 
Cornell University. He is the author of 237 published articles in leading medical, epidemiological, 
statistics, and science journals, cited over 25,000 times in peer-reviewed scientific journals. Dr. 
Kulldorff is recognized internationally for his foundational research on the detection and 
monitoring of disease outbreaks and on the monitoring and evaluation of vaccine safety issues.  
His epidemiological methods are routinely used by the Centers for Disease Control and Prevention 
(“CDC”), the Food and Drug Administration (“FDA”) and other public health agencies around the 
world.  
3. 
Both of us have dedicated our professional careers to the analysis of public health 
data, including infectious disease epidemiology and policy, and the efficacy and safety of medical 
interventions. 
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4. 
We have both studied extensively and commented publicly on the necessity and 
safety of vaccine requirements for those who have contracted and recovered from COVID-19 
(individuals who have “natural immunity”). We are intimately familiar with the emergent scientific 
and medical literature on this topic and pertinent government policy responses to the issue both in 
the United States and abroad. 
5. 
Our assessment of vaccine immunity is based on studies related to the efficacy and 
safety of the three vaccines that have received Emergency Use Authorization (“EUA”) from the 
Food and Drug Administration (FDA) for use in the United States. These include two mRNA 
technology vaccines (manufactured by Pfizer-BioNTech and Moderna) and an adenovirus vector 
vaccine technology (manufactured by Johnson & Johnson).  
6. 
Neither of us has received any financial or other compensation to prepare this 
Declaration. Nor have we ever received any personal or research funding from any pharmaceutical 
company. In writing this, we are motivated solely by our commitment to public health. 
7. 
Neither of us has an existing doctor-patient relationship with Jeanna Norris. 
8. 
We have been asked to provide our opinion on several matters related to Michigan 
State University (“MSU” or “University”) vaccine policy for faculty and staff (the “mandatory 
vaccination” directive), including the following: 
a. Whether, based on the current medical and scientific knowledge, natural immunity 
is categorically inferior to vaccine immunity to prevent reinfection and 
transmission of the SARS-CoV-2 virus; 
b. Whether, based on the existing medical and scientific understanding of SARS-
CoV-2 transmission and recovery, there is any categorical distinction between 
natural immunity and vaccine immunity; and 
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c. An assessment of the comparative safety to recipients of administering vaccines to 
those who have natural immunity relative to immunologically naïve recipients with 
no prior history of COVID infection.  
9. 
Our opinions are summarized in a recent article we published and which we 
reaffirm here: “[R]ecovered COVID patients have strong, long-lasting protection against severe 
disease if reinfected, and evidence about protective immunity after natural infection is stronger 
than the evidence from the vaccines. Hence, it makes no sense to require vaccines for recovered 
COVID patients. For them, it simply adds a risk, however small.”1 
Mortality Risk from COVID-19 Infection and Corresponding Marginal Benefit From 
Vaccination Varies By Orders of Magnitude Based on Age 
 
10. 
The mortality risk posed by COVID infection is a basic parameter necessary to 
understand the public health benefits from vaccines. The best evidence on the infection fatality 
rate from SARS-CoV-2 infection (that is, the fraction of infected people who die due to the 
infection) comes from seroprevalence studies. The definition of seroprevalence of COVID-19 is 
the fraction of people within a population who have specific antibodies against SARS-CoV-2 in 
their bloodstream. Seroprevalence studies provide better evidence on the total number of people 
who have been infected than do case reports or a positive reverse transcriptase-polymerase chain 
reaction (RT-PCR) test counts; these both miss infected people who are not identified by the public 
health authorities or do not volunteer for RT-PCR testing. Because they ignore unreported cases 
in the denominator, fatality rate estimates based on case reports or positive test counts are 
substantially biased upwards. According to a meta-analysis (published by the World Health 
Organization) by Dr. John Ioannidis of every seroprevalence study conducted with a supporting 
 
1 Martin Kuldorff and Jay Bhattacharya, The ill-advised push to vaccinate the young, THEHILL.COM (June 17, 2021), 
https://thehill.com/opinion/healthcare/558757-the-ill-advised-push-to-vaccinate-the-young?rl=1. 
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scientific paper (74 estimates from 61 studies and 51 different localities worldwide), the median 
infection survival rate from COVID-19 infection is 99.77%. For COVID-19 patients under 70, the 
meta-analysis finds an infection survival rate of 99.95%.2 A newly released meta-analysis by 
scientists independent of Dr. Ioannidis’ group reaches qualitatively similar conclusions.3   
11. 
The mortality risk for those infected with SARS-CoV-2 is not the same for all 
patients. Older patients are at higher risk of death if infected, while younger patients face a 
vanishingly small risk.4 The same is true for hospitalization risk, which is similarly age-dependent. 
The best evidence on age-specific infection fatality rates comes again from seroprevalence studies.  
12. 
The CDC’s best estimate of the infection fatality ratio for people ages 0-19 years is 
0.00002, meaning infected children have a 99.998% infection survivability rate.5 The CDC’s best 
estimate of the infection fatality rate for people ages 20-49 years is 0.0005, meaning that young 
adults have a 99.95% survivability rate. The CDC’s best estimate of the infection fatality rate for 
people age 50-64 years is 0.006, meaning this age group has a 99.4% survivability rate. The CDC’s 
best estimate of the infection fatality rate for people ages 65+ years is .09, meaning seniors have a 
91.0% survivability rate. 
13. 
A study of the seroprevalence of COVID-19 in Geneva, Switzerland (published in 
the Lancet)6 provides a detailed age breakdown of the infection survival rate in a preprint 
 
2 Ioannidis JPA, Infection fatality rate of COVID-19 inferred from seroprevalence data, BULL WORLD HEALTH ORGAN 
(Jan 1, 2021). 
3 Andrew T. Levin, et al., Assessing the Age Specificity of Infection Fatality Rates for COVID-19: Meta-Analysis & 
Public Policy Implications,  MEDRXIV (Aug. 14, 2020), https://bit.ly/3gpIoIV. 
4 Kulldorff M., COVID-19 Counter Measures Should Be Age-Specific, LINKEDIN (Apr. 10, 2020), 
https://www.linkedin.com/pulse/covid-19-counter-measures-should-age-specific-martin-kulldorff/. 
5 
Centers 
for 
Disease 
Control 
and 
Prevention, 
COVID-19 
Pandemic 
Planning 
Scenarios,  
https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html. 
6 Silvia Stringhini, et al., Seroprevalence of Anti-SARS-CoV-2 IgG Antibodies in Geneva, Switzerland (SEROCoV-
POP): A Population Based Study,THE LANCET (June 11, 2020), https://bit.ly/3l87S13. 
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companion paper7: 99.9984% for patients 5 to 9 years old; 99.99968% for patients 10 to 19 years 
old; 99.991% for patients 20 to 49 years old; 99.86% for patients 50 to 64 years old; and 94.6% 
for patients above 65 years old.  
14. 
In summary, the mortality risk posed by COVID infection in the young is 
vanishingly small, while the threat posed to the elderly is orders of magnitude higher.  One direct 
corollary of this point is that the corresponding personal benefit from vaccination, at least as far as 
mortality risk is concerned, is orders of magnitude lower for the young relative to the elderly. 
Another corollary is that the community benefit from vaccines mandates is orders of magnitude 
lower for a university compared to say a nursing home, whee the average age is much higher.   
Both Vaccine Immunity and Natural Immunity Provide Durable Protection Against 
Reinfection and Against Severe Outcomes If Reinfected 
 
15. 
Both vaccine-mediated immunity and natural immunity after recovery from 
COVID infection provide extensive protection against severe disease from subsequent SARS-
CoV-2 infection.  There has never been a reason to presume that vaccine immunity provides a 
higher level of protection than natural immunity, and there is now evidence that natual immunity 
is stronger than vaccine immunity.  Since vaccines arrived one year after the disease, there is also 
stronger evidence for long lasting immunity from natural infection than from the vaccines. 
16. 
Both types are based on the same basic immunological mechanism—stimulating 
the immune system to generate an antibody response. In clinical trials, the efficacy of those 
vaccines was initially tested by comparing the antibodies level in the blood of vaccinated 
individuals to those who had natural immunity. Later Phase III studies of the vaccines established 
 
7 Francisco Perez-Saez, et al., Serology-Informed Estimates of SARS-COV-2 Infection Fatality Risk in Geneva, 
Switzerland, OSF PREPRINTS (June 15, 2020), https://osf.io/wdbpe/. 
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94%+ clinical efficacy of the mRNA vaccines against severe COVID illness.8,9  A Phase III trial 
showed 85% efficacy for the Johnson and Johnson adenovirus-based vaccine against severe 
disease.10  
17. 
Immunologists have identified many immunological mechanisms of immune 
protection after recovery from infections. Studies have demonstrated prolonged immunity with 
respect to memory T and B cells11, bone marrow plasma cells12, spike-specific neutralizing 
antibodies 13,  and IgG+ memory B cells14 following naturally acquired immunity. 
 
8 Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, Diemert D, Spector SA, Rouphael N, Creech CB, 
McGettigan J, Khetan S, Segall N, Solis J, Brosz A, Fierro C, Schwartz H, Neuzil K, Corey L, Gilbert P, Janes H, 
Follmann D, Marovich M, Mascola J, Polakowski L, Ledgerwood J, Graham BS, Bennett H, Pajon R, Knightly C, 
Leav B, Deng W, Zhou H, Han S, Ivarsson M, Miller J, Zaks T., COVE Study Group. Efficacy and Safety of the 
mRNA-1273 SARS-CoV-2 Vaccine, N ENGL J MED (Feb. 4, 2021). 
9 Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini 
C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW Jr, Hammitt LL, 
Türeci Ö, Nell H, Schaefer A, Ünal S, Tresnan DB, Mather S, Dormitzer PR, Şahin U, Jansen KU, Gruber WC, Safety 
and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine, N ENGL J MED. (Dec. 31, 2020). 
10 Sadoff J, Gray G, Vandebosch A, Cárdenas V, Shukarev G, Grinsztejn B, Goepfert PA, Truyers C, Fennema H, 
Spiessens B, Offergeld K, Scheper G, Taylor KL, Robb ML, Treanor J, Barouch DH, Stoddard J, Ryser MF, Marovich 
MA, Neuzil KM, Corey L, Cauwenberghs N, Tanner T, Hardt K, Ruiz-Guiñazú J, Le Gars M, Schuitemaker H, Van 
Hoof J, Struyf F, Douoguih M, Safety and Efficacy of Single-Dose Ad26.COV2.S Vaccine against Covid-19, N ENGL 
J MED (June 10, 2021), 2187-2201. 
11 Jennifer M. Dan, et al., Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection, SCIENCE 
(Feb. 5, 2021) (finding that memory T and B and B cells were present up to eight months after infection, noting that 
“durable immunity against secondary COVID-19 disease is a possibility for most individuals”). 
12 Jackson S. Turner, et al., SARS-CoV-2 infection induces long-lived bone marrow plasma cells in humans, NATURE 
(May 24, 2021) (study analyzing bone marrow plasma cells of recovered COVID-19 patients reported durable 
evidence of antibodies for at least 11 months after infection, describing “robust antigen-specific, long-lived humoral 
immune response in humans”); Ewen Callaway, Had COVID? You’ll probably make antibodies for a lifetime, NATURE 
(May 
26, 
2021), 
https://www.nature.com/articles/d41586-021-01442-
9#:~:text=Many%20people%20who%20have%20been,recovered%20from%20COVID%2D191 
(“The 
study 
provides evidence that immunity triggered by SARS-CoV-2 infection will be extraordinarily long-lasting” and “people 
who recover from mild COVID-19 have bone-marrow cells that can churn out antibodies for decades”). 
13 Tyler J. Ripperger, et al., Orthogonal SARS-Cov-2 Serological Assays Enable Surveillance of Low-Prevalence 
Communities and Reveal Durable Humor Immunity, 53 IMMUNITY, Issue 5, pp. 925-933 E4 (Nov. 17, 2020) (study 
finding that spike and neutralizing antibodies remained detectable 5-7 months after recovering from infection). 
14 Kristen W. Cohen, et al., Longitudinal analysis shows durable and broad immune memory after SARS-CoV-2 
infection with persisting antibody responses and memory B and T cells, MEDRXIV (Apr. 27, 2021), 
https://www.medrxiv.org/content/10.1101/2021.04.19.21255739v1 (study of 254 recovered COVID patients over 8 
months “found a predominant broad-based immune memory response” and “sustained IgG+ memory B cell response, 
which bodes well for rapid antibody response upon virus re-exposure.” “Taken together, these results suggest that 
broad and effective immunity may persist long-term in recovered COVID-19 patients”). 
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18. 
Multiple extensive, peer-reviewed studies comparing natural and vaccine immunity 
have now been published. These studies show that natural immunity provides greater protection 
against severe infection than immunity generated by mRNA vaccines (Pfizer and Moderna).  
19. 
Specifically, studies confirm the efficacy of natural immunity against reinfection 
of COVID-1915 and show that the vast majority of reinfections are less severe than first-time 
infections.16 For example, an Israeli study of approximately 6.4 million individuals demonstrated 
that natural immunity provided excellent protection in preventing COVID-19 infection, morbidity, 
and mortality.17 Of the 187,549 unvaccinated persons with natural immunity in the study, only 894 
 
15 Nabin K. Shrestha, et al., Necessity of COVID-19 vaccination in previously infected individuals, MEDRXIV 
(preprint), 
https://www.medrxiv.org/content/10.1101/2021.06.01.21258176v3. (“not one of the 1359 previously infected 
subjects who remained unvaccinated had a SARS-CoV-2 infection over the duration of the study “and concluded that 
those with natural immunity are “unlikely to benefit from covid-19 vaccination”); Galit Perez, et al., A 1 to 1000 
SARS-CoV-2 reinfection proporation in members of a large healthcare provider in Israel: a preliminary report, 
MEDRXIV (Mar. 8, 2021), https://www.medrxiv.org/content/10.1101/2021.03.06.21253051v1 (Israeli study finding 
that approximately 1/1000 of participants were reinfected); Roberto Bertollini, et al,. Associations of Vaccination and 
of Prior Infection With Positive PCR Test Results for SARS-CoV-2 in Airline Passengers Arriving in Qatar, JAMA 
(June 9, 2021), https://jamanetwork.com/journals/jama/fullarticle/2781112?resultClick=1 (study of international 
airline passengers arriving in Qatar found no statistically significant difference in risk of reinfection between those 
who had been vaccinated and those who had previously been infected); Stefan Pilz, et al., SARS-CoV-2 re-infection 
risk in Austria, EUR. J. CLIN. INVEST. (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988582/(previous 
SARS-CoV-2 infection reduced the odds of re-infection by 91% compared to first infection in the remaining general 
population); Aodhan Sean Breathnach, et al., Prior COVID-19 protects against reinfection, even in the absence of 
detectable antibodies, 82 J. OF INFECTION e11-e12 (2021) https://doi.org/10.1016/j.jinf.2021.05.024 (.0.86% of 
previously infected population in London became reinfected); Alison Tarke, Negligible impact of SARS0CoV-2 
variants on CD4 and CD8 T cell reactivity in COVID-19 exposed donors and vaccines, BIORXIV (Mar. 1, 2021), 
https://www.biorxiv.org/content/10.1101/2021.02.27.433180v1 (an examination of the comparative efficacy of T cell 
responses to existing variants from patients with natural immunity compared to those who received an mRNA vaccine 
found that the T cell responses of both recovered Covid patients and vaccines were effective at neutralizing mutations 
found in SARS-CoV-2 variants). 
16 Laith J. Abu-Raddad, et al., SARS-CoV-2 reinfection in a cohort of 43,000 antibody-positive individuals followed 
for up to 35 weeks, MEDRXIV (Feb. 8, 2021), https://www.medrxiv.org/content/10.1101/2021.01.15.21249731v2 
(finding that of 129 reinfections from a cohort of 43,044, only one reinfection was severe, two were moderate, and 
none were critical or fatal); Victoria Jane Hall, et al., SARS-CoV-2 infection rates of antibody-positive compared with 
antibody-negative health-care workers in England: a large, multicentre, prospective cohort study, 397 LANCET: 1459-
69 (Apr. 9, 2021), https://pubmed.ncbi.nlm.nih.gov/33844963/ (finding “a 93% lower risk of COVID-19 symptomatic 
infection… [which] show[s] equal or higher protection from natural infection, both for symptomatic and asymptomatic 
infection”); Aidan T. Hanrah, et al., Prior SARS-CoV-2 infection is associated with protection against symptomatic 
reinfection, 
82 
JOURNAL 
OF 
INFECTION, 
Issue 
4, 
E29-E30 
(Apr. 
1, 
2021), 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832116/  (Apr. 1, 2021) (examined reinfection rates in a cohort of 
healthcare workers and found “no symptomatic reinfections” among those examined and that protection lasted for at 
least 6 months). 
17 Yair Goldberg, et al., Protection of previous SARS-CoV-2 infection is similar to that of BNT162b2. 
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(0.48%) were reinfected; 38 (0.02%) were hospitalized, 16 (0.008%) were hospitalized with severe 
disease, and only one died, an individual over 80 years of age.  
20. 
A more recent study from Israel directly compare natual immunity with vaccine 
immunity.18 The study compares previously infected and recovered individuals who did not 
receive a vaccine after their recovery against individuals who received the Pfizer vaccine without 
having had the disease. The study considered four primary endpoints: a positive COVID test (a 
surrogate endpoint of limited value); symptomatic COVID-19 disease, hospitalization for COVID-
19 disease, and COVID-19 associated mortality (all recorded in the months after recovery or 
vaccination). The study adjusts for age, demographic variables, patient comorbidities, and the 
timing of the disease/vaccine. The primary findings are that vaccinated individuals had 13.1 times 
higher risk of testing positive [95% CI: 8.08-21.1], 27 times higher risk of symptomatic disease 
[95% CI: 12.7-57.5], ~8.1 times higher risk of COVID-related hospitalization [95% CI: 1.01-
64.55]. None of the patients in the study died due to COVID-related mortality. The vaccinated 
individuals were also at higher risk compared to those that had COVID disease before the vaccines 
became available. The authors concluded: 
This study demonstrated that natural immunity confers longer lasting and stronger 
protection against infection, symptomatic disease and hospitalization caused by the 
Delta variant of SARS-CoV-2, compared to the BNT162b2 two-dose vaccine-
induced immunity.  
 
 
vaccine protection: A three-month nationwide experience from Israel, MEDRXIV (pre-print), 
https://www.medrxiv.org/content/10.1101/2021.04.20.21255670v1. 
18 Sivan Gazit, Roei Shlezinger, Galit Perez, Roni Lotan, Asaf Peretz, Amir Ben-Tov, Dani Cohen, Khitam Muhsen, 
Gabriel Chodick, Tal Patalon (2021)  Comparing SARS-CoV-2 natural immunity to vaccine-induced immunity: 
reinfections versus breakthrough infections.  medRxiv. August 25, 2021.  doi: 
https://doi.org/10.1101/2021.08.24.21262415. 
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21. 
Based on such evidence, many scientists have concluded that natural protection 
against severe disease after COVID recovery is likely to be long-lasting.19 
22. 
These findings of highly durable natural immunity should not be surprising, as they 
hold for SARS-CoV-1 and other respiratory viruses. According to a paper published in Nature in 
August 2020, 23 patients who had recovered from SARS-CoV-1 still possess CD4 and CD8 T 
cells, 17 years after infection during the 2003 epidemic.20 A Nature paper from 2008 found that 
32 people born in 1915 or earlier still retained some level of immunity against the 1918 flu strain—
some 90 years later.21  
23. 
In contrast to the concrete findings regarding the robust durability of natural 
immunity, it is yet unclear in the scientific literature how long-lasting vaccine-induced immunity 
will be. Notably, researchers have argued that they can best surmise the predicted durability of 
vaccine immunity by looking at the expected durability of natural immunity.22  
24. 
In short, there is no medical or scientific reason to believe that vaccine immunity is 
superior to or will prove longer-lasting than natural immunity, much less that all currently 
approved vaccines will be expected to prove more durable than natural immunity despite their 
different technological foundations and dosing protocols.  
Vaccine Side Effects Do Occur, Including Rare But Deadly Side Effects  
25. 
Though the COVID vaccines are safe by the standards of many other vaccines 
approved for use in the population, like all medical interventions, they have side effects. In 
 
19 Chris Baranjuk, How long does covid-19 immunity last? 373 BMJ (2021) (emphasis added). 
20 Nina Le Bert, SARS-CoV-2-specific T cell immunity in cases of COVID-19 and SARS, and uninfected control, 
NATURE (Aug. 2020). 
21 Xiaocong Yu, et al., Neutralizing antibodies derived form the B cells of 1918 influenze pandemic survivors, NATURE 
(2008). 
22 Heidi Ledford, Six months of COVID vaccines: what 1.7 billion doses hove taught scientists, 594 NATURE 164 (June 
10, 2021),  https://www.nature.com/articles/d41586-021-01505-x (study notes that “Six months is not much time to 
collect data on how durable vaccine responses will be…. In the meantime some researchers are looking to natural 
immunity as a guide.”). 
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summarizing the evidence on vaccine side effects, the CDC lists both common side effects, at least 
one of which occurs in over half of all people who receive the vaccines, as well as deadly side 
effects that occur rarely in demographic subsets of the vaccinated population.  
26. 
The common side effects include pain and swelling at the vaccination site and 
fatigue, headache, muscle pain, fever, and nausea for a limited time after vaccination.23  Less 
common but severe side effects also include severe and non-severe allergic (anaphylactic) 
reactions that can occur within 30 minutes after vaccination, which can typically be treated with 
an epinephrine injection if it occurs.24 Finally, the CDC’s vaccine safety committee has identified 
rare but deadly side effects, including a heightened risk of clotting abnormalities25 in young women 
after the Johnson & Johnson (J&J) vaccination, elevated risks of myocarditis and pericarditis26 in 
young people — but especially young men — after mRNA vaccination, and higher risk of 
Guillane-Barre Syndrome27 after the J&J vaccine. There is still the possibility of severe side effects 
that have yet to be identified as the vaccines have been in use in human populations for less than 
a year. Active investigation to check for safety problems is still ongoing.  
27. 
Though the CDC28 still recommends the vaccines for children 12 years old and up 
despite the evidence of elevated risk of myocarditis, other analysts29 have objected to overly rosy 
 
23 Centers for Disease Control, Possible Side Effects After Getting a COVID-19 Vaccine (June 24, 2021), 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html. 
24 Centers for Disease Control, What to Do If You Have an Allergic Reaction after Getting a COVID-19 Vaccine (June 
24, 2021), https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/allergic-reaction.html. 
25 Martin Kulldorff, The Dangers of Pausing the J&J Vaccine, THE HILL (April 17, 2021), 
https://thehill.com/opinion/healthcare/548817-the-dangers-of-pausing-the-jj-vaccine. 
26 Centers for Disease Control, Myocarditis and Pericarditis after Receipt of mRNA COVID-19 Vaccines Among 
Adolescents 
and 
Young 
Adults 
(May 
28, 
2021), 
https://www.cdc.gov/vaccines/covid-19/clinical-
considerations/myocarditis.html. 
27 LaFranier and Weiland, FDA Attaches Warning of Rare Nerve Syndrome to Johnson & Johnson Vaccine, NEW 
YORK TIMES (July 12, 2021), https://www.nytimes.com/2021/07/12/us/politics/fda-warning-johnson-johnson-
vaccine-nerve-syndrome.html. 
28 Walensky, CDC Director Statement on Pfizer’s Use of COVID-19 Vaccine in Adolescents Age 12 and Older (May 
12, 2021), https://www.cdc.gov/media/releases/2021/s0512-advisory-committee-signing.html. 
29 Pegden,  Weighing myocarditis cases, ACIP failed to balance the harms vs benefits of 2nd doses (June 24, 2021), 
https://medium.com/@wpegden?p=d7d6b3df7cfb. 
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assumptions made in the CDC analysis about vaccine side effects. They suggest that the 
recommendation is fragile to minor perturbation in their assumptions. The critical point for our 
analysis – undisputed in the scientific literature – is that the vaccines do have side effects, some of 
which are severe and not all of which are necessarily known at this point in time. 
28. 
While uncertain, some clinical evidence indicates that those who have recovered 
from COVID-19 could potentially have a heightened risk of adverse effects compared with those 
who have never had the virus.30 31 This may be because vaccine reactogenicity after the first dose 
is higher among those with prior natural immunity.32  
Variants Do Not Alter the Conclusion that Vaccine Mandates Are Unwarranted 
29. 
Since its spread through the human population, the SARS-CoV-2 virus   –  an RNA 
virus – has been mutating, including some forms that are likely more transmissible than the original 
wild-type virus that emerged from Wuhan, China, in 2019.  The virus will continue to mutate as it 
continues to spread.   However, the possibility of such a mutation does not alter the conclusion 
that a vaccine mandate is unwarranted. 
 
30 Alexander G. Mathioudakis, et al., Self-Reported Real-World Safety and Reactogenicity of COVID-19 Vaccines: A 
Vaccine Recipient Survey, 11 LIFE 249 (Mar. 2021). 
31 Cristina Menni, Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID symptom 
study app in the UK: a prospective observational study, 21 LANCET INFECTIOUS DISEASES 939-49 (July 2021) 
(finding that “Systemic side-effects were more common (1.6 times after the first dose of ChAdOx1 nCoV-19 [i.e., 
AstraZeneca vaccine] and 2.9 times after the first dose of BNT162b2 [i.e., Pfizer/BioNTech vaccine]) among 
individuals with previous SARS-CoV-2 infection than among those without known past infection. Local effects 
were similarly higher in individuals previously infected than in those without known past infection (1.4 times after 
the first dose of ChAdOx1 nCoV-19 and 1.2 times after the first dose of BNT162b2).”). 
32 Florian Krammer, et al., Robust spike antibody responses and increased reactogenitiy in seropositive individuals 
after a singe dose of SARS-CoV-2 mRNA vaccine, MEDRXIV (Feb. 1, 2021), 
https://www.medrxiv.org/content/10.1101/2021.01.29.21250653v1 (concluding that “vaccine reactogenicity after 
the first dose is substantially more pronounced in individuals with pre-existing immunity.” The authors note that 
“quantitative serological assays that measure antibodies to the spike protein could be used to screen individuals prior 
to vaccination,” which would “limit the reactogenicity experienced by COVID-19 survivors.). 
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30. 
First, the mutant variants do not escape the immunity provided by prior infection 
with the wild-type virus or vaccination.33,34,35  Although reinfection can occur, people who have 
been previously infected by the wild-type (non-variant) virus are unlikely to have a severe outcome 
(hospitalization or death) after exposure to a variant virus. A variant circulating in the population 
thus poses little additional risk of hospital overcrowding or excess mortality due to viral infection.  
31. 
Second, theoretical work suggests that lockdowns place selective pressure that 
promotes the development and establishment of more deadly variants. This, in part, may explain 
why the most concerning variants have emerged in places like the U.K., South Africa, and 
California, where severe lockdowns have been imposed for extended periods.36 While this 
hypothesis awaits a definitive empirical test, it is consistent with the prima facie evidence on 
mutant variants’ development.  
32. 
Third, the variants have been widely spreading in many countries these past 
months, even as cases have dropped. This is true, for instance, in Florida, where the U.K. variant 
B.1.1.7 was widespread this past winter37, but cases fell sharply over the same period that the 
variant has been spreading. That variants with an infectivity advantage – but no more lethality –
 
33 Alison Tarke, A., Sidney, J., Methot, N., Zhang, Y., Dan, J. M., Goodwin, B., Rubiro, P., Sutherland, A., da Silva 
Antunes, R., Frazier, A., Rawlings, S. A., Smith, D. M., Peters, B., Scheuermann, R. H., Weiskopf, D., Crotty, S., 
Grifoni, A., & Sette, A., Negligible impact of SARS-CoV-2 variants on CD4 + and CD8 + T cell reactivity in COVID-
19 exposed donors and vaccinees, BIORXIV, 2021.02.27.433180 (2021), https://doi.org/10.1101/2021.02.27.433180. 
34 Wu, K., Werner, A. P., Moliva, J. I., Koch, M., Choi, A., Stewart-Jones, G. B. E., Bennett, H., Boyoglu-Barnum, 
S., Shi, W., Graham, B. S., Carfi, A., Corbett, K. S., Seder, R. A., & Edwards, D. K., mRNA-1273 vaccine induces 
neutralizing antibodies against spike mutants from global SARS-CoV-2 variants, BIORXIV : THE PREPRINT SERVER 
FOR BIOLOGY, 2021.01.25.427948 (2021), https://doi.org/10.1101/2021.01.25.427948. 
35 Redd, A. D., Nardin, A., Kared, H., Bloch, E. M., Pekosz, A., Laeyendecker, O., Abel, B., Fehlings, M., Quinn, T. 
C., & Tobian, A. A., CD8+ T cell responses in COVID-19 convalescent individuals target conserved epitopes from 
multiple prominent SARS-CoV-2 circulating variants, MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES, 
2021.02.11.21251585 (2021), https://doi.org/10.1101/2021.02.11.21251585. 
36 Moran J., Mutant variations and the danger of lockdowns, THE CRITIC MAGAZINE (March 2, 2021), 
https://thecritic.co.uk/mutant-variations-and-the-danger-of-lockdowns/. 
37 
US 
Centers 
for 
Disease 
Control, 
US 
COVID-19 
Cases 
Caused 
by 
Variants 
(2021), 
https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant-cases.html. 
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make up a larger fraction of a smaller number of cases is an interesting scientific observation but 
not crucial for public health policy. 
33. 
Fourth, the dissemination of vaccines that protect against hospitalizations and 
deaths upon COVID-19 infection throughout the older population in the United States has 
decoupled the growth in COVID-19 cases from COVID-19 mortality. Vaccinated people can still 
perhaps be infected but rarely have severe symptoms in response to infection. Throughout last 
year, a rise in cases was inevitably accompanied by an increase in deaths with a two-to-three-week 
lag. However, during this most recent wave, there has been little rise in daily deaths to accompany 
the rise in cases because of the deployment of the vaccine in the vulnerable older population in the 
United States. The same is true in Sweden and the U.K., where vaccines have been provided to the 
entirety of the vulnerable elderly population and more.38 Because of the success of the American 
vaccination effort among the vulnerable elderly, COVID-19 cases and COVID-19 deaths are now 
effectively decoupled.  
The Presence of Lingering Post-Viral Infection Symptoms in a Subset of Recovered COVID 
patients (“Long COVID”) Does Not Alter The Conclusion that Vaccine Mandates Are 
Unwarranted  
34. 
Some analysts and politicians have used the possibility that a fraction of patients 
who recover from COVID infection will experience lingering symptoms to justify vaccine 
mandates and lockdown measures. Long COVID, as this phenomenon is called, includes a 
complex set of clinical outcomes with a poorly understood link to acute COVID infection.39 One 
cross-sectional study found that about 30% of recovered COVID patients reported at least one 
 
38Jay Bhattacharya, Martin Kulldorff, and Sunetra Gupta, Sweden’s Lessons for the UK’s Third Wave, THE 
SPECTATOR (July 12, 2021), https://www.spectator.co.uk/article/sweden-shows-that-the-uk-s-third-wave-won-t-
sting. 
39 Nalbandian, A., Sehgal, K., Gupta, A. et al., Post-acute COVID-19 syndrome, NAT MED 27, 601–615 (2021), 
https://doi.org/10.1038/s41591-021-01283-z. 
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symptom months after recovery, with fatigue and anosmia (loss of sense of smell) by far the most 
common.40 A separate study with a more convincing longitudinal methodology, by contrast, 
concluded that 2.3% of patients experienced such symptoms three months after recovery.41 
Patients who suffered a more severe acute course of COVID, including hospitalization, were more 
likely to report lingering symptoms after recovery.42 A study of children who recovered from 
COVID found the same rate of long COVID symptoms as a control group of children who had no 
serological evidence of prior COVID infection.43 Some analysts have noted the similarity between 
“long COVID” symptoms and other functional somatic syndromes that sometimes occur after 
other viral infections and other triggers (and sometimes with no identifiable etiology).44  
35. 
To summarize, as with other viruses, long COVID symptoms occur in a minority 
of patients who recover from COVID and pose a real burden on patients who suffer from it. 
However, this fact does not alter the logic of our argument. On the countrary. After suffering 
through COVID, with or without long COVID, such individuals should not be forces to also endure 
common but mild vaccine adverse reactions or risk rare but serious adverse reactions.  Moreover, 
the successful vaccine rollout in the United States – where every teenager and adult has free access 
to the vaccines – addresses the problem of long COVID, just as it addresses COVID-associated 
mortality. 
CDC Recommendation for Vaccination of Recovered COVID Patients Applies With Equal 
Force to Previously Vaccinated  
 
40 Logue JK, Franko NM, McCulloch DJ, et al., Sequelae in Adults at 6 Months After COVID-19 Infection, JAMA 
NETW OPEN (2021);4(2):e210830, doi:10.1001/jamanetworkopen.2021.0830. 
41 Sudre, C.H., Murray, B., Varsavsky, T. et al., Attributes and predictors of long COVID, NAT MED 27, 626–631 
(2021), https://doi.org/10.1038/s41591-021-01292-y. 
42 Arnold DT, Hamilton FW, Milne A, et al., Patient outcomes after hospitalisation with COVID-19 and 
implications for follow-up: results from a prospective UK cohort, THORAX, 76:399-401 (2021). 
43 Thomas Radtke, Agne Ulyte, Milo A Puhan, Susi Kriemler, Long-term symptoms after SARS-CoV-2 infection in 
school children: population-based cohort with 6-months follow-up, MEDRXIV (2021), 
https://doi.org/10.1101/2021.05.16.21257255. 
44 Ballering A, Olde Hartman T, Rosmalen J Long COVID-19, persistent somatic symptoms and social 
stigmatization, J EPIDEMIOL COMMUNITY HEALTH (2021). 
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36. 
Written before the Israel study, the CDC, in a frequently asked questions section of 
a website encouraging vaccination, provided the following advice to previously recovered patients 
in July 2021:45 
Yes, you should be vaccinated regardless of whether you already had COVID-19. 
That’s because experts do not yet know how long you are protected from getting 
sick again after recovering from COVID-19. Even if you have already recovered 
from COVID-19, it is possible—although rare—that you could be infected with the 
virus that causes COVID-19 again. Studies have shown that vaccination provides a 
strong boost in protection in people who have recovered from COVID-19. Learn 
more about why getting vaccinated is a safer way to build protection than getting 
infected. 
 
37. 
The last sentence is true but irrelevant for people with natural immunity. The 
statement on CDC’s website that “studies have shown that vaccination provides a strong boost in 
protection in people who have recovered from COVID-19,” is incorrect. As one would expect, 
people with prior COVID-19 disease have increased levels of antibodies after receiving the 
vaccine, leading to fewer positive tests, just as if they are re-exposed to the disease. This does not 
mean that the vaccine increases protection against symptomatic disease, hospitalizations or deaths. 
In an update to the website46 on August 19, 2021, the CDC links to a single study from Kentucky.47 
That study showed fewer positive tests among those who had both natural immunity and a vaccine, 
but the study did not evaluate the relevant outcomes of symptomatic disease, hospitalizations, 
deaths or transmission. Like the Kentucky study, the Israel study also found that those with both 
natural immunity and a vaccine were less likely to test positive compared with those with natural 
 
45 US Centers for Disease Control (2021) Frequently Asked Questions About COVI19 Vaccination. 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html (accessed July 30, 2021) 
46 US Centers for Disease Control (2021) Frequently Asked Questions About COVI19 Vaccination. 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html (accessed August 26, 2021) 
47 Cavanaugh AM, Spicer KB, Thoroughman D, Glick C, Winter K. Reduced Risk of Reinfection with SARS-CoV-
2 After COVID-19 Vaccination — Kentucky, May–June 2021. MMWR Morb Mortal Wkly Rep 2021;70:1081-
1083. DOI: http://dx.doi.org/10.15585/mmwr.mm7032e1 
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immunity but no vaccine. The Israel study also evaluated other outcomes, and did not find any 
statistically significant difference with respect to symptomatic disease, hospitalizations or deaths, 
all of which were very low in both groups (e.g. no deaths in either group).  
38. 
The text of this advice by the CDC also does not address any of the scientific 
evidence we have provided in our declaration, herein, about the lack of necessity for recovered 
COVID patients to be vaccinated. While it is true that we do not know how long natural immunity 
after recovery lasts, in terms of 5, 10, or 20 years from now, the immunological evidence to date 
suggests that protection against disease will last for years.48  
39. 
That is because, with exceedingly few reinfections among millions of recovered 
COVID-19 patients, we know that there is excellent protection for at least 18 months, and that 
protection is not suddenly going to disappear after exactly 18 months.  
40. 
 Uncertainty over the longevity of immunity after recovery is a specious reason for 
not exempting COVID recovered patients from vaccination mandates, since the same is true to an 
even highe degree about vaccine mediated immunity. We do not know how long it will last either, 
and there is no reason to believe it provides longer lasting or more complete immunity than 
recovery from COVID.  
41. 
Similarly, just as reinfections are possible though rare after COVID recovery, 
breakthrough infections are possible after vaccination, as the CDC’s team investigating vaccine 
breakthrough infections itself recognizes.49 On the same CDC FAQ webpage we cite above50, the 
 
48 Patel N (2021) Covid-19 Immunity Likely Lasts for Years. MIT Technology Review. January 6, 2021. 
https://www.technologyreview.com/2021/01/06/1015822/covid-19-immunity-likely-lasts-for-years/ 
49 CDC COVID-19 Vaccine Breakthrough Case Investigations Team (2021) COVID-19 Vaccine Breakthrough 
Infections Reported to CDC — United States, January 1–April 30, 2021. May 28, 2021. 
https://www.cdc.gov/mmwr/volumes/70/wr/mm7021e3.htm 
50 US Centers for Disease Control (2021) Frequently Asked Questions About COVI19 Vaccination. 
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html 
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CDC writes about vaccine mediated immunity, “We don’t know how long protection lasts for 
those who are vaccinated.” 
42. 
The CDC’s main concern in this FAQ seems to be to help people understand that it 
is safer to attain immunity against SARS-CoV-2 infection via vaccination rather than via infection. 
This is a point not in dispute.  Rather, the question is whether someone who already has been 
infected and recovered will benefit on net from the additional protection provided by vaccination. 
On this point, the CDC’s statement in the FAQ is non-responsive, and ignores the scientific 
evidence. 
Conclusion 
43. 
A fundamental ethical principle guiding the practice of medicine is that any medical 
intervention, whether surgical, pharmacological, or a vaccine, should be recommended and 
undertaken only if it is deemed medically necessary. Any medical procedure, including 
vaccination, involves risk. No medical procedure is 100% safe, especially those involving a new 
vaccine which by definition has not been studied for long-term adverse side effects. For this reason, 
it is a fundamental principle of medical ethics that the risks of the procedure be balanced against 
the potential benefits.   
44. 
As we established earlier, based on the scientific evidence to date, those who have 
recovered from a SARS-CoV-2 infection possess immunity as robust and durable as that acquired 
through vaccination.  In Jeanna Norris’ case, there is no doubt that, based on recent measures of 
her antibody levels, she is protected by natural immunity (Dr. Bhattacharya has examined the 
results from Ms. Norris’ laboratory tests). The results indicate the presence of both spike-protein 
and nucleocapsid protein antibodies; the latter is a reliable sign of previous natural infection (the 
former turns positive after either previous natural infection or vaccination). The existing clinical 
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literature overwhelmingly indicates that the protection afforded to the individual and community 
from natural immunity is as effective and durable as the efficacy levels of the most effective 
vaccines to date. From the point of view of Ms. Norris’ personal health, there is no good reason 
that she should be vaccinated. At the very least, the decision should be left to Ms. Norris and her 
doctors without coercion applied by the University. 
45. 
There is also no community health reason for the University to mandate 
vaccinations since she already has stonge immunity than those that ae vaccinated, and the vaccine 
is available to all teens and adults who want it. Indeed, based on our analysis of the existing medical 
and scientific literature, any policy mandating vaccinations that does not recognize natural 
immunity is irrational, arbitrary, and counterproductive to community health.51  
46. 
As we wrote in the Wall Street Journal this spring, “[t]he idea that everybody needs 
to be vaccinated is as scientifically baseless as the idea that nobody does. Covid vaccines are 
essential for older, high-risk people and their caretakers and advisable for many others. But those 
who've been infected are already immune . . .  .If authorities mandate vaccination of those who 
don't need it, the public will start questioning vaccines in general . . . . Coercive vaccination policies 
would erode trust even further.”52  
47. 
We criticized those pushing for and implementing vaccine mandates as 
“undermining public trust in vaccines. In this sense, they are more dangerous than the small group 
of so-called anti-vaxxers have ever been.” 
 
51 Jay Bhattacharya, Sunetra Gupta, and Martin Kulldorff, The Beauty of Vaccines and Natural Immunity, 
SMERCONISH NEWSLETTER (June 4, 2021), https://www.smerconish.com/exclusive-content/the-beauty-of-vaccines-
and-natural-immunity. 
52 Martin Kulldorff and Jay Bhattacharya, Vaccine Passports Prolong Lockdowns, WALL STREET JOURNAL (Apr. 6, 
2021), https://www.wsj.com/articles/vaccine-passports-prolong-lockdowns-11617726629. 
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48. 
It is unethical to coerce low-risk Americans to take the vaccine, such as low-risk 
students and those with natual immunity, while older high-risk individuals in Asia, Africa and 
Latin America are dying from COVID19 because there are not enough vaccines available in those 
countries.   
49. 
Now that every American adult and teenager has free access to the vaccines, the 
case for a vaccine mandate is even weaker than it was in the spring when we wrote that Wall Street 
Journal piece. There is no good public health case for MSU to require proof of vaccination for 
employees and students to participate in University activities that do not involve care for high-risk 
patients.  And, since those recovered from COVID19 has better protection than vaccinated 
individuals, there are no public health reasons to impose different mask requirements for the two 
groups.    
50. 
Since the successful vaccination campaign already protects the vulnerable 
population, even the unvaccinated who have not had COVID disease –pose a vanishingly small 
threat to the vaccinated o those with natual immunity. They are protected by an effective vaccine, 
that dramatically reduces the likelihood of hospitalization or death after infections to near zero, o 
by natural immunity.  
51. 
With widespread vaccination of the vulnerable, asymptomatic people pose even 
less risk to the vulnerable than before the vaccine became available. At the same time, the 
requirement for a vaccine passport or other type of proof of vaccine undermines trust in public 
health because of its coercive nature. While vaccines are an excellent tool for protecting the 
vulnerable, COVID does not justify ignoring principles of good public health practice that caution 
against warrantless discrimination against segments of the population (in this case, the 
unvaccinated).  
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52. 
We recently observed that “[u]niversities used to be bastions of enlightenment. 
Now many of them ignore basic benefit-risk analyses, a staple of the toolbox of scientists; they 
deny immunity from natural infection; they abandon the global international perspective for 
narrow nationalism; and they replace trust with coercion and authoritarianism. Mandating the 
COVID-19 vaccine thus threatens not only public health but also the future of science.”53 
53. 
Universities can be leaders in developing sensible policies grounded in sound 
scientific evidence and abide by the fundamental principles of medical ethics. Individuals who 
have recovered from COVID-19 should be exempt from any vaccine mandates and treated as in 
an identical position to those who have been vaccinated.   
 
Respectfully submitted, 
 
Dr. Jay Bhattacharya, MD, Ph.D. 
 
Dr. Martin Kulldorff, Ph.D. 
Professor of Medicine  
 
 
Professor of Medicine 
Stanford University 
 
 
 
Harvard University 
 
 
53 Martin Kuldorff and Jay Bhattacharya, The ill-advised push to vaccinate the young, THEHILL.COM (June 17, 2021), 
https://thehill.com/opinion/healthcare/558757-the-ill-advised-push-to-vaccinate-the-young?rl=1. 
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EXHIBIT B 
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Page 1 of 12 
 
Declaration of Dr. Hooman Noorchashm, MD, PhD 
I, Hooman Noorchashm, provide the following Joint Declaration and hereby declare under 
penalty of perjury under the laws of the United States of America that the foregoing is true 
and correct: 
Background 
 
1. 
I graduated from the Perelman School of Medicine at the University of 
Pennsylvania with a Doctorate degree in immunology and a Medical Doctorate in 2001/2002, 
under a “Medical Scientist Training Program” fellowship grant from the National Institutes of 
Health. I subsequently completed residencies in general surgery and cardiothoracic surgery from 
2004-2013, first at the Hospital of the University of Pennsylvania and then at Harvard’s Brigham 
and Women’s Hospital. I also completed a post-doctoral research fellowship in Immunology and 
served as Principal Investigator on several Immunology research grants from the NIH. I have 
taught and practiced clinical medicine for nearly two decades. In addition to an academic career 
in medicine, I am an advocate for patient safety and medical ethics.  
2. 
I have served on the clinical and research faculties at the University of Pennsylvania 
School of Medicine, Harvard Medical School Brigham and Women’s Hospital, Thomas Jefferson 
University Hospital, and the Philadelphia VA Hospital. I have authored over 65 articles, abstracts, 
and reviews in peer-reviewed medical journals, including the New England Journal of Medicine, 
Journal of Immunology, Nature Medicine, American Journal of Transplantation, Critical Care 
Medicine, and Diabetes. I am currently a practicing physician with unrestricted medical licenses 
in the states of Pennsylvania and New Jersey. I have testified on numerous occasions before the 
Food and Drug Administration and state legislatures on issues related to medicine, immunology, 
patient safety, and patient’s rights. 
3. 
In 2013, my wife Dr. Amy Josephine Reed underwent a hysterectomy operation 
using a dangerous indiscriminate surgical procedure, which we later learned spread a misdiagnosed 
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uterine cancer and advanced it to stage 4 Leiomyosarcoma. She eventually died from 
complications related to indiscriminate, one-size-fits-all morcellation of her symptomatic uterine 
fibroid tumors. 
4. 
Before her death, my wife and I began spreading awareness of this indiscriminate 
procedure’s danger and advocating for patient safety and patient’s rights. In recognition of those 
efforts, I received a Health Policy Heroes Award from the National Center for Health Research in 
2015. This advocacy is fundamentally focused on the principles of ethical practice guided by the 
medical ethical ideas of “medical necessity” and “patient autonomy” – and a total rejection of non-
personalized and algorithmic “one-size-fits-all” service line practices, wherein harm to minority 
subsets of patients is a near-certainty. 
5. 
To continue the work that Dr. Amy Josephine Reed and I started, I founded the 
American Patient Defense Union, Inc. (APDU), an organization dedicated to advocating for patient 
rights and autonomy, preserving the integrity and sacred relationship between doctors and their 
patients, and protecting doctor and patient decisions about medical treatments from third-party 
influence.1 This organization is involved with advocacy for, and defense of, individual patients or 
minority subsets of persons harmed by unsafe or unnecessary medical practices without adequate 
informed consent or inadequate evidence supporting their use.  
 
 
 
 
 
1 See Hooman Noorchashm, Why Does Every American Need The American Patient Defense Union (APDU)?, 
MEDIUM.COM (Oct. 17, 2017), https://noorchashm.medium.com/why-every-american-needs-the-american-patient-
defense-union-apdu-2912e1fee5d4.  
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Jeanna Norris’s Medical Condition 
6. 
On August 20, 2021, Ms. Norris contacted me for a consultation on how to 
determine the status of her immunity to COVID-19. I agreed to review her case and provide my 
opinion. 
7. 
During a phone call that same day, Ms. Norris informed me of the following 
relevant facts: 
a. On November 19, 2020, she fell ill with a severe headache and a dry cough.  
b. In the early morning hours of November 20, 2020, she was awakened by severe 
myalgias, arthralgia and a headache. 
c. Ms. Norris undwerent a Rapid COVID Antigen test on November 21, 2020, which 
came back positive. 
d. Her severe symptoms of body ache and headache lasted for 4 days and were not 
associated with any significant effects– these symptoms lingered for 
approximately 30 days. 
e. Ms. Norris lost her sense of taste and smell on day 4-5 following onset of her 
symptoms. This sensory deficit lasted for approximately 30 days. 
f. After an extensive discussion about her medical condition, I issued a prescription 
for full COVID-19 serological screening, which was conducted on August 20, 
2021, at LabCorp. Ms. Norris underwent a blood draw that same day. I examined 
the results and, as expected, the test confirmed that Ms. Norris had previously 
recovered from SARS-CoV-2 and had both a positive IgG Spike Antibody assay 
and a positive SARS-CoV-2 Nucleocapsid result.  
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g. Ms. Norris’ semiquantitative antibody reading measured 59.7 U/ml—
approximately 70 times higher than the baseline level of <0.8 U/ml. This level is 
comparable to that I have seen empirically in many persons with acquired natural 
immunity to SAR-CoV-2 from a prior infection. In my opinion, Ms. Norris’ spike 
antibody level is highly likely to be above the minimum necessary to provide 
adequate protection against re-infection from the SARS-CoV-2 virus. 
Principles of Medical Ethics and Michigan State University’s (MSU’s) Vaccine Mandate 
8. 
There are four basic principles governing medical ethics in the United States: (1) 
autonomy, (2) justice, (3) beneficence, and (4) non-maleficence.  
9. 
A highly influential public health framework proposed by Childress, et al., lists five 
conditions that public health interventions must satisfy: (1) effectiveness, (2) proportionality, (3) 
necessity, (4) least infringement, and (5) public justification.2  
10. 
The principle of necessity is reinforced by the principle of “least infringement,” 
which requires that any intervention “seek to minimize the infringement of general moral 
considerations.” In particular, “when a policy infringes autonomy, public health agents should seek 
the least restrictive alternative; when it infringes privacy, they should seek the least intrusive 
alternative.”3 
11. 
The principle of proportionality is also a defense against one-size-fits-all 
approaches that can cause harm in the context of medicine. 
 
 
 
2 James F. Childress, et al., Public Health Ethics: Mapping the Terrain, 30(2) J. LAW & MED. ETHICS 170 (2002). 
 
3 Id. 
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It is Medically Unnecessary for Ms. Norris to Undergo Vaccination Against SARS-CoV-2, 
and Forcing her to Do So Would Subject Her to an Elevated Risk of Adverse Side Effects 
 
12. 
It is my opinion that undergoing a full course vaccination (two doses of an mRNA 
vaccination or one dose of the Johnson and Johnson [J&J] vaccine) is medically unnecessary and 
creates a risk of harm to Ms. Norris in light of her pre-established acquired immunity to SARS-
CoV-2, while providing insignificant or no benefit to her or the MSU community. 
13. 
A highly sensitive and specific antibody test has confirmed that Ms. Norris 
contracted and recovered from the SARS-CoV-2 virus. Her recent semi-quantitative antibodies 
screening test established that her level of immune protection remains high.  
14. 
A series of epidemiological studies have demonstrated to a reasonable degree of 
medical certainty that natural immunity following infection and recovery from the SARS-CoV-2 
virus provides robust and durable protection against reinfection, at levels equal to or better than 
the most effective vaccines currently available.4  
15. 
 For example, according to the Centers for Disease Control (CDC), in clinical trials 
the J&J vaccine provides an efficacy of only 66.3%—far below any measured efficacy of natural 
immunity to date. 
16. 
Natural immunity protection to SARS-CoV-2 has already proven long-lasting and 
experience with prior coronaviruses strongly indicates that T-cell immunity provided by natural 
immunity could last years or even decades. 
17. 
In my opinion, it is almost certainly true that natural infection provides broad-based 
protection against SARS-CoV-2 variants. Unlike vaccine-induced immunity, which is specialized 
 
4 Cites (Cleveland clinic, England, Israel, etc.); N. Kojima, et al., Incidence of Severe Acute Respiratory Syndrome 
Coronavirus-2 
infection 
among 
previously 
infected 
or 
vaccinated 
employees, 
https://www.medrxiv.org/content/10.1101/2021.07.03.21259976v2 (July 8, 2021). 
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to target the Spike-protein of the original Wuhan variant of the SARS-CoV-2 virus, natural 
immunity recognizes the full complement of SARS-CoV-2 proteins, enabling it to provide 
protection against a greater array of variants. Emerging evidence is already confirming this 
immunological expectation.   
18. 
Furthermore, based on my analysis of the clinical medical literature to date, 
undergoing a full course of vaccine treatment (two doses of mRNA or one dose of J&J vaccine) 
as required by MSU’s vaccine mandate, in a setting of a prior infection and being immune, would 
expose Ms. Norris to an elevated risk of adverse effects, including serious ones, when compared 
with individuals who have never contracted COVID-19.  
19. 
Any medical procedure carries the risk of adverse side effects. The SARS-CoV-2 
vaccines are no exception. In many cases, the benefits of curing, mitigating, or preventing greater 
harm justifies undertaking a particular medical intervention notwithstanding any associated risk. 
But basic principles of medical ethics mandate that any potential benefits be weighed against the 
risks associated with the procedure. It is critical for any given medical treatment, including 
vaccination, to be delivered only in the setting of medical necessity in any given individual – and 
certainly if medical necessity is ruled out for any given medical treatment, forcing the treatment 
on any such person is unethical. 
20. 
Because Ms. Norris has previously been infected with and recovered from SARS-
CoV-2, in my opinion, a vaccination is unnecessary and could only subject her to the risk of harm 
with little to no tangible added benefit to her or the MSU community relative to “fully vaccinated” 
persons.  
21. 
Additionally, it is becoming clear that undergoing vaccination in the setting of 
having had a prior infection subjects her to an elevated risk of adverse side effects compared to 
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those who have not previously been infected.  Existing clinical reports indicate that individuals 
with a prior infection and natural immunity actually face an elevated risk of adverse effects from 
receiving the vaccine compared to those who have never contracted COVID-19. 
22. 
 According to a study in the medical journal Life (March 2021), “our study links 
prior COVID-19 illness with an increased incidence of vaccination side effects and demonstrates 
that mRNA vaccines cause milder, less frequent systemic side effects but more local reactions.”5 
The elevated side effects identified in the article include events such as anaphylaxis, swelling, flu-
like illness, breathlessness, fatigue, and others, some requiring hospitalization. 
23. 
A study published in The Lancet Infectious Diseases (July 1, 2021) examined 
reports from 627,383 individuals using the COVID Symptom Study app. The authors reported a 
higher incidence of both systemic and local side effects from receiving the first vaccine dose for 
those who had previously been infected with COVID-19 compared to those who had not 
previously been infected.6  
24. 
A study conducted at Mount Sinai Icahn School of Medicine also found among 
those receiving their first vaccine dose, “vaccine reactogenicity” was “substantially more 
pronounced in individuals with pre-existing immunity” than those who had not previously been 
infected and those with pre-existing immunity experienced “systemic side effects with a 
significantly higher frequency” than those who had not previously been infected. 
 
5 Alexander G. Mathioudakis, et al., Self-Reported Real-World Safety and Reactogenicity of COVID-19 Vaccines: A 
Vaccine Recipient Survey, 11 LIFE 249 (Mar. 2021). 
6 Cristina Menni, Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID symptom 
study app in the UK: a prospective observational study, 21 LANCET INFECTIOUS DISEASES 939-49 (July 2021). 
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25. 
In addition, there are numerous nonsystematic reports of individuals who have had 
unusually severe adverse reactions to vaccination shortly after recovering from COVID-19 
infections.7  
26. 
Notably many of these studies focused on the adverse effects of receiving just the 
first dose of a vaccine. They do not examine the frequency or severity of receiving a second dose 
of a vaccine. This uncertainty is especially important in light of the widespread recognition that 
those with natural immunity gain no significant benefit from receipt of a second vaccine dose (as 
is required by MSU’s mandatory vaccination policy). 
27. 
It is a fundamental principle of immunology that “vaccinating a person who is 
recently or concurrently infected can reactivate, or exacerbate, a harmful inflammatory response 
to the virus. This is NOT a theoretical concern.”8 This applies to SARS-CoV-2 just as it does to 
any virus. 
28. 
To date, none of the vaccines in current application have been systematically or 
adequately tested for safety or efficacy in individuals who have previously been infected and 
recovered from SARS-CoV-2. In fact, Covid survivors have overall been largely excluded from 
Phase III vaccine clinical trials.9 Thus, any determination with respect to the safety profile of the 
vaccines in this population, of which Ms. Norris is a member, can only be inferred from clinical 
studies in the time since the vaccines have been put into widespread application. 
 
7 See Multisystem Inflammatory Syndrome after SARS-CoV-2 Infection and COVID-19 Vaccination, 27 (Number 7) 
EMERGING INFECTIOUS DISEASE (July 2021) (Centers for Disease Control and Prevention Dispatch); see also 
Hooman Noorchashm, CDC Knows Vaccine Associated Critical Illness and Myocarditis are Linked to Prior 
COVID-19 Infections, MEDIUM.COM (Jun 2, 2021), https://noorchashm.medium.com/cdc-knows-vaccine-associated-
critical-illness-and-myocarditis-are-linked-to-prior-covid-19-62942c39c5ca. 
8 Homman Noorchashm, The Recently Infected and Already Immune DO NOT Benefit from COVID-19 Vaccination, 
MEDIUM.COM (Jun 1, 2021), https://noorchashm.medium.com/the-recently-infected-and-already-immune-do-not-
benefit-from-covid-19-infection-7453886e8c89.  
9 See Fabio Angeli, SARS-CoV-2 vaccines: Lights and shadows, 88 EUROPEAN J. OF INTERNAL MEDICINE 1-8 
(2021). 
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29. 
A recent study from the state of Kentucky suggested that COVID-recovered 
individuals who undergo added vaccination enjoy some marginal added benefit relative to 
COVID-recovered persons who are not vaccinated. However, this study did not compare the risk 
of subsequent infection in COVID-recovered, vaccinated persons versus those who are COVID-
naïve and “fully vaccinated.” 
30. 
 The preponderance of evidence from other studies indicates that COVID-
recovered individuals, in fact, enjoy the same level of protection from subsequent infection, 
perhaps more, when compared to persons considered “fully vaccinated” using the adenoviral or 
mRNA vaccines. This latter comparison is the only relevant comparison that could have possibly 
justified any discriminatory practice against COVID-recovered, already immune people relative 
to “fully vaccinated” persons – IF there was any real difference between the two groups.  
31. 
Additionally, the Kentucky study did not address or attempt to quantify the 
magnitude of risk and adverse effects in its comparison groups. Yet, other studies have 
demonstrated that in fact, the rate of adverse vaccination events is significantly higher in persons 
previously infected.  Overall, it is my opinion that though the Kentucky study may make a case 
for COVID-recovered persons being offered a choice to be vaccinated if they choose to enjoy 
added protection, it is not ethical for MSU, or any other institution, to use the CDC’s Kentucky 
study results to institute discriminatory practices in COVID-recovered, already immune persons 
versus “fully vaccinated” persons. It is my opinion that the Kentucky study does not compare the 
appropriate groups to justify forced vaccination of and discriminatory practices against COVID-
recovered Americans. 
32. 
In contrast to the determination that Ms. Norris has reached after consultation with 
me, about the details of her personal situation and medical history, MSU is inappropriately, and in 
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violation of the rules governing medical ethics, imposing a “one-size-fits-all” vaccine mandate on 
her and every member of the MSU community who is in an analogous situation to her. 
33. 
MSU does not know the details of Ms. Norris’ situation and evidence of her existing 
immunity levels or potential for adverse effects, such as the results of any quantitative antibodies 
screening test.  
34. 
MSU’s vaccine mandate is forcing Ms. Norris to choose between following 
ethically sound medical practice on one hand and being subject to MSU’s burdensome and punitive 
discriminatory practices – which includes being forced to socially distance, remain socially 
isolated, or undergo frequent COVID-19 testing – on the other. No American should be put in such 
a position. 
35. 
As with all patients, Ms. Norris and her consulting physicians should determine her 
future course of medical treatment. Thus, I will continue to monitor Ms. Norris’s antibody levels 
as SARS-CoV-2 variants arise and/or her immune protection starts to wane. A this point in time, 
it is my opinion that neither Ms. Norris nor the MSU community are at any higher risk of being 
infected because of her autonomous choice to delay or forego a booster vaccination at this time.  
 
MSU’s Goals in Promoting Community Safety Can Be Accomplished More Effectively and 
with Less Harm Through Alternative, Less-Restrictive/Coercive Means 
 
36. 
Protecting the MSU community from COVID-19 transmission can be achieved 
without exposing COVID-recovered and already immune members of the community to the risk 
of harm, in contrast to MSU’s current indiscriminate vaccination plan. 
37. 
The emerging consensus in the clinical literature on the protective benefits of 
acquired natural immunity compared to the elevated risks of indiscriminately vaccinating these 
individuals has led me to propose the personalized #ScreenB4Vaccine initiative for individual 
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American who correctly believe that medical necessity is the underpinning of safe medical 
practice.10 #ScreenB4Vaccine contains two elements: (1) testing for the presence of natural 
immunity through widespread antibody testing, and (2) a test for presence of an active infection, 
before vaccination. 
38. 
In fact, growing recognition of the highly protective character of acquired natural 
immunity in preventing reinfection, along with the elevated risk of vaccinating those who have 
natural immunity, has recently led the European Union to recognize “a record of previous 
infection” as a valid substitute for vaccination.11 
39. 
Certainly, the Israeli Green Passport system allows for COVID-recovered persons 
with evidence of antibody immunity to be treated identically to those “fully vaccinated.”  
40. 
In short, just because an individual is vaccinated does not guarantee she is immune 
and just because she is not vaccinated does not mean she is not immune. “Immunity,” as assessed 
by the presence of antibodies to SARS-CoV-2 Spike protein, is at the core of protection from 
SARS-CoV-2 infection – not vaccination, per se. 
41. 
Instead of focusing its policy on blanket vaccination, therefore, MSU’s policy 
should instead focus on immunity, regardless of how it is obtained.  
Conclusion 
42. 
I call on MSU to act responsibly and, based on the principles of sound medical 
ethics and immunology, to recognize the importance of acquired natural immunity in providing 
protection equal to or better than existing vaccines.  Such a policy would also acknowledge, and 
 
10 See Hooman Noorchashm, What is #ScreenB4Vaccine? And Why Is It Necessary for Keeping Every American 
Maximally Safe in the COVID-19 Pandemic? MEDIUM.COM (May 7, 2021), https://noorchashm.medium.com/what-
is-screenb4vaccine-80b639c4984e.  
11 See Julia Buckley, EU Digital Covid Certificate: Everything you need to know, CNN.COM (June 9, 2021), 
https://www.cnn.com/travel/article/eu-covid-certificate-travel-explainer/index.html. 
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therefore avoid, the elevated risk of side effects from vaccination among those who have already 
survived a SARS-CoV-2 infection and are recovered within the past year. 
Respectfully submitted, 
   /s/ Hooman Noorchashm___________ 
Hooman Noorchashm MD, PhD. 
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EXHIBIT C 
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1283   Filed 11/05/21   Page 35 of 92

UNITED STATES DISTRICT COURT  
FOR THE WESTERN DISTRICT OF MICHIGAN 
 
 
JEANNA NORRIS, KRAIG EHM, and 
D’ANN ROHRER, individually and on 
behalf of all others similarly situated, et al.,  
 
 
 
 
 
 
 
Plaintiffs, 
 
 
 
v. 
  
Civil Action No.: 21-cv-00756-PLM 
 
SAMUEL STANLEY, et al.  
 
 
 
 
 
 
Defendants. 
 
 
 
 
DECLARATION OF DR. JAYANTA BHATTACHARYA SUPPORTING PLAINTIFFS 
I, Dr. Jayanta Bhattacharya, declare as follows: 
1. I am an adult of sound mind and make this statement voluntarily, based upon my own 
personal knowledge, education, and experience. 
2. Based on my training and experience, I have formed an opinion on the reasonableness 
of the requested accommodations and on the possibility of other accommodations not listed to a 
reasonable degree of scientific certainty. 
EXPERIENCE & CREDENTIALS 
3. I am a former Professor of Medicine and current Professor of Health Policy at Stanford 
University School of Medicine and a research associate at the National Bureau of Economic 
Research. I am also Director of Stanford’s Center for Demography and Economics of Health and 
Aging. I hold an M.D. and Ph.D. from Stanford University. I have published 154 scholarly articles 
in peer-reviewed journals in the fields of medicine, economics, health policy, epidemiology, 
statistics, law, and public health, among others. My research has been cited in the peer-reviewed 
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2 
 
scientific literature more than 11,600 times. My curriculum vitae is attached to this declaration as 
Exhibit A. 
4. 
I have dedicated my professional career to the analysis of health policy, including 
infectious disease epidemiology and policy, and the safety and efficacy of medical interventions. 
I have both studied extensively and commented publicly on the necessity and safety of vaccine 
requirements for those who have contracted and recovered from COVID-19 (individuals who 
have “natural immunity”). I am intimately familiar with the emergent scientific and medical 
literature on this topic and pertinent government policy responses to the issue both in the United 
States and abroad. 
5. 
My assessment of vaccine immunity is based on studies related to the efficacy and 
safety of the one vaccine to receive full approval from the Food and Drug Administration (FDA) 
and the two vaccines that the FDA has granted Emergency Use Authorization (EUA) for use in 
the United States. These include two mRNA-technology vaccines (manufactured by Pfizer-
BioNTech and Moderna) and an adenovirus-vector vaccine technology (manufactured by Johnson 
& Johnson). Of those, the Pfizer vaccine, also known as Comirnaty, has full FDA approval. 
6. 
I have not and will not receive any financial or other compensation to prepare this 
Declaration or to testify in this case. Nor have I received compensation for preparing declarations 
or reports or for testifying in any other case related to the COVID-19 pandemic, or any personal 
or research funding from any pharmaceutical company. My participation here has been motivated 
solely by my commitment to public health, just as my participation in other cases has been. 
7. I have no prior relationship with any of the plaintiffs. 
8. I have been asked to provide my opinion on several matters related to Michigan State 
University’s vaccine policy for its employees, including the following: 
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3 
 
• Whether, based on the current medical and scientific knowledge, immunity after 
COVID recovery (sometimes referred to as natural immunity) is categorically inferior 
to vaccine immunity to prevent reinfection and transmission of the SARS-CoV-2 virus; 
• Whether, based on the existing medical and scientific understanding of SARS-CoV-2 
transmission and recovery, there is any categorical distinction between natural 
immunity and vaccine immunity;  
• An assessment of the comparative safety to recipients of administering vaccines to those 
who have natural immunity relative to immunologically naïve recipients with no prior 
history of COVID infection; 
• Whether vaccines pose any risks to individuals with certain medical conditions; 
• The safety of providing accommodations to those who have recovered from COVID; 
and 
• What those accommodations could look like in practice. 
9. My opinions are partly summarized in a recent article I published and which I reaffirm 
here: “[R]ecovered COVID patients have strong long-lasting protection against severe disease if 
reinfected, and evidence about protective immunity after natural infection is at least as good as 
from the vaccines. Hence, it makes no sense to require vaccines for recovered patients. For them, 
it simply adds a risk, however small, without any benefit.”1  
10. I also offer my opinion that certain individuals may face heightened risk of vaccine 
side effects. Though the vaccines are safe for most patients, the FDA has identified a heightened 
risk of myocarditis and pericarditis after vaccination with the mRNA vaccines – especially for 
 
1 Kulldorff, M., & Bhattacharya, J. (2021, June 17). The ill-advised push to vaccinate the young. The Hill.  
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young men. It has also identified a heightened risk of clotting abnormalities in young women 
taking the adenovirus vector vaccine. Even more importantly, the vaccine has not been thoroughly 
tested for safety and efficacy in patients with certain chronic conditions such as Multiple Sclerosis, 
so there is still considerable scientific uncertainty about these heightened risks for some patients. 
11. I also conclude that MSU can safely accommodate COVID-recovered employees by 
exempting them from vaccine requirements since they possess better immunity via prior infection 
than a vaccinated worker who never had COVID possesses from vaccination. MSU could also 
safely accommodate those employees who have not previously been infected with from COVID-
19 but have religious or medical reasons for not wanting the vaccine by requiring daily symptom 
checking paired with rapid antigen tests to confirm if a worker is infectious. To reduce the risk 
from asymptomatically infected workers, MSU can require workers to conduct weekly PCR or 
antigen tests, though if it adopts this accommodation, it would be best practice to require it of both 
vaccinated and unvaccinated employees since both groups can spread the virus asymptomatically. 
If implemented, these accommodations would keep MSU’s campus as safe as possible from the 
risk of COVID infection, while preserving the employment of numerous MSU employees. 
OPINIONS 
I. 
Natural Immunity Provides Durable Protection Against Reinfection and Against 
Severe Outcomes If Reinfected; COVID-19 Vaccines Provide Limited Protection 
Against Infection but Durable Protection Against Severe Outcomes if Infected. 
 
12. Both vaccine-mediated immunity and natural immunity after recovery from COVID 
infection provide extensive protection against severe disease from subsequent SARS-CoV-2 
infection. There is no reason to presume that vaccine immunity provides a higher level of 
protection than natural immunity. Since vaccines arrived one year after the disease, there is 
stronger evidence for long lasting immunity from natural infection than from the vaccines. 
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13. Both types are based on the same basic immunological mechanism—stimulating the 
immune system to generate an antibody response. In clinical trials, the efficacy of those vaccines 
was initially tested by comparing the antibody levels in the blood of vaccinated individuals to 
those who had natural immunity. Later Phase III studies of the vaccines established 94%+ clinical 
efficacy of the mRNA vaccines against severe COVID illness.2, 3 A Phase III trial showed 85% 
efficacy for the Johnson & Johnson adenovirus-based vaccine against severe disease.4 
14. Immunologists have identified many immunological mechanisms of immune 
protection after recovery from infections. Studies have demonstrated prolonged immunity with 
respect to memory T and B cells5, bone marrow plasma cells6, spike-specific neutralizing 
 
2 Baden, L. R., El Sahly, H. M., Essink, B., Kotloff, K., Frey, S., Novak, R., Diemert, D., Spector, S. A., 
Rouphael, N., Creech, C. B., McGettigan, J., Khetan, S., Segall, N., Solis, J., Brosz, A., Fierro, C., Schwartz, H., 
Neuzil, K., Corey, L., Zaks, T. for the COVE Study Group (2021). Efficacy and Safety of the mRNA-1273 SARS-
CoV-2 Vaccine. The New England Journal of Medicine, 384(5), 403-416. doi: 10.1056/NEJMoa2035389   
3 Polack, F. P., Thomas, S. J., Kitchin, N., Absalon, J., Gurtman, A., Lockhart, S., Perez, J. L., Pérez Marc, G., 
Moreira, E. D., Zerbini,  C., Bailey, R., Swanson, K. A., Roychoudhury, S., Koury, K., Li, P., Kalina, W. V., 
Cooper, D., Frenck, R. W. Jr., Hammitt, L. L., Gruber, W. C. (2020). Safety and Efficacy of the BNT162b2 mRNA 
Covid-19 Vaccine. The New England Journal of Medicine, 387(27), 2603-2615.  doi: 10.1056/NEJMoa2034577 
4 Sadoff, J., Gray, G., Vandebosch, A., Cárdenas, V., Shukarev, G., Grinsztejn, B., Goepfert, P. A., Truyers, C., 
Fennema, H., Spiessens, B., Offergeld, K., Scheper, G., Taylor, K. L., Robb, M. L., Treanor, J., Barouch, D. H., 
Stoddard, J., Ryser, M. F., Marovich,  M. A., Douoguih, M. for the ENSEMBLE Study Group. (2021). Safety and 
Efficacy of Single-Dose Ad26.COV2.S Vaccine against Covid-19. The New England Journal of Medicine, 384(23), 
2187-2201. doi: 10.1056/NEJMoa2101544 
5 Dan, J. M., Mateus, J., Kato, Y., Hastie, K. M., Yu, E. D., Faliti, C. E., Grifoni, A., Ramirez, S. I., Haupt, S., 
Frazier, A., Nakao, C., Rayaprolu, V., Rawlings, S. A., Peters, B., Krammer, F., Simon, V., Saphire, E. O., Smith, 
D. M., Weiskopf, D., Crotty, S. (2021). Immunological memory to SARS-CoV-2 assessed for up to 8 months after 
infection. Science, 371, 1-13. doi: 10.1126/science.abf4063 (finding that memory T and B cells were present up to 
eight months after infection, noting that “durable immunity against secondary COVID-19 disease is a possibility in 
most individuals”). 
6 Turner, J. S., Kim, W., Kalaidina, E., Goss, C. W., Rauseo, A. M., Schmitz, A. J., Hansen, L., Haile, A., 
Klebert, M. K., Pusic, I., O’Halloran, J. A., Presti, R. M. & Ellebedy, A. H. (2021). SARS-CoV-2 infection induces 
long-lived bone marrow plasma cells in humans. Nature, 595(7867), 421-425. doi: 10.1038/s41586-021-03647-4 
(study analyzing bone marrow plasma cells of recovered COVID-19 patients reported durable evidence of antibodies 
for at least 11 months after infection, describing “robust antigen-specific, long-lived humoral immune response in 
humans”); Callaway, E. (2021, May 26). Had COVID? You’ll probably make antibodies for a lifetime. Nature.  
https://www.nature.com/articles/d41586-021-01442-
9#:~:text=Many%20people%20who%20have%20been,recovered%20from%20COVID%2D191 
(“The 
study 
provides evidence that immunity triggered by SARS-CoV-2 infection will be extraordinarily long-lasting” and 
“people who recover from mild COVID-19 have bone-marrow cells that can churn out antibodies for decades”). 
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6 
 
antibodies7,  and IgG+ memory B cells8 following naturally acquired immunity. 
15. Multiple extensive, peer-reviewed studies comparing natural and vaccine immunity 
have now been published. These studies overwhelmingly conclude that natural immunity provides 
equivalent or greater protection against severe infection than immunity generated by mRNA 
vaccines (Pfizer and Moderna). 
16. Specifically, studies confirm the efficacy of natural immunity against reinfection of 
COVID-199 and show that the vast majority of reinfections are less severe than first-time 
 
7 Ripperger, T. J., Uhrlaub, J. E., Watanabe, M., Wong, R., Castaneda, Y., Pizzato, H. A., Thompson, M. R., 
Bradshaw, C., Weinkauf, C. C., Bime, C., Erickson, H. L., Knox, K., Bixby, B., Parthasarathy, S., Chaudhary, S., 
Natt, B., Cristan, E., El Aini, T., Rischard, F., Bhattacharya, D. (2020). Orthogonal SARS-CoV-2 serological assays 
enable surveillance of low-prevalence communities and reveal durable humor immunity. Immunity, 53(5), 925-933. 
doi: 10.1016/j.immuni.2020.10.004 (study finding that spike and neutralizing antibodies remained detectable 5-7 
months after recovering from infection). 
8 Cohen, K. W., Linderman, S. L., Moodie, Z., Czartoski, J., Lai, L., Mantus, G., Norwood, C., Nyhoff, L. E., 
Edara, V. V., Floyd, K., De Rosa, S. C., Ahmed, H., Whaley, R., Patel, S. N., Prigmore, B., Lemos, M. P., Davis, C. 
W., Furth, S., O’Keefe, J., McElrath, M. J. (2021). Longitudinal analysis shows durable and broad immune memory 
after SARS-CoV-2 infection with persisting antibody responses and memory B and T cells. medRxiv, Preprint. (study 
of 254 recovered COVID patients over 8 months “found a predominant broad-based immune memory response” and 
“sustained IgG+ memory B cell response,  which bodes well for rapid antibody response upon virus re-exposure.” 
“Taken together, these results suggest that broad and effective immunity may persist long-term in recovered COVID-
19 patients”). 
9 Shrestha, N. K., Burke, P. C., Nowacki, A. S., Terpeluk, P. & Gordon, S. M. (2021). Necessity of COVID-19 
vaccination in previously infected individuals. medRxiv, Preprint. doi: 10.1101/2021.06.01.21258176 (“not one of 
the 1359 previously infected subjects who remained unvaccinated had a SARS-CoV-2 infection over the duration of 
the study” and concluded that  those with natural immunity are “unlikely to benefit from COVID-19 vaccination”); 
Perez, G., Banon, T., Gazit, S., Moshe, S. B., Wortsman, J., Grupel, D., Peretz, A., Tov, A. B., Chodick, G., Mizrahi-
Reuveni, M., & Patalon, T. (2021). A 1 to 1000 SARS-CoV-2 reinfection proportion in members of a large healthcare 
provider in Israel: A preliminary report. medRxiv, Preprint.  doi: 10.1101/2021.03.06.21253051 (Israeli study finding 
that approximately 1/1000 of participants were reinfected); Bertollini, R., Chemaitelly, H., Yassine, H. M., Al-Thani, 
M. H., Al-Khal, A., & Abu-Raddad, L. J. (2021). Associations of vaccination and of prior infection with positive PCR 
test results for SARS-CoV-2 in airline passengers arriving in Qatar. JAMA, 326(2), 185-188. doi: 
10.1001/jama.2021.9970 (study of international airline passengers arriving in Qatar found no statistically significant 
difference in risk of reinfection between those who had been vaccinated and those who had previously been infected); 
Pilz, S., Chakeri, A., Ioannidis, J. P. A., Richter, L., Theiler-Schwetz, V., Trummer, C., Krause, R., Allerberger, F. 
(2021). SARS-CoV-2 re-infection risk in Austria. European Journal of Clinical Investigation, 51(4), 1-7. doi: 
10.1111/eci.13520  (previous SARS-CoV-2 infection reduced the odds of re-infection by 91% compared to first 
infection in the remaining general  population); Breathnach, A. S., Duncan, C. J. A., El Bouzidi, K., Hanrath, A. T., 
Payne, B. A. I., Randell, P. A., Habibi, M. S., Riley, P. A., Planche, T. D., Busby, J. S., Sudhanva, M., Pallett, S. J. C. 
& Kelleher, W. P. (2021). Prior COVID-19 protects against reinfection, even in the absence of detectable antibodies. 
The Journal of Infection, 83(2), 237-279. doi: 10.1016/j.jinf.2021.05.024 (0.86% of previously infected population in 
London became reinfected); Tarke, A., Sidney, J., Methot, N., Yu, E. D., Zhang, Y., Dan, J. M., Goodwin, B., Rubiro, 
P., Sutherland, A., Wang, E., Frazier, A.,  Ramirez, S. I., Rawlings, S. A., Smith, D. M., da Silva Antunes, R., Peters, 
B., Scheuermann, R. H., Weiskopf, D., Crotty, S., Grifoni, A. & Sette, A. (2021). Impact of SARS-CoV-2 variants on 
the total CD4+ and CD8+ T cell reactivity in infected or vaccinated individuals, Cell Reports Medicine 2(7), 100355 
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infections.10 For example, an Israeli study of approximately 6.4 million individuals demonstrated 
that natural immunity provided equivalent if not better protection than vaccine immunity in 
preventing COVID-19 infection, morbidity, and mortality.11 Of the 187,549 unvaccinated persons 
with natural immunity in the study, only 894 (0.48%) were reinfected; 38 (0.02%) were 
hospitalized, 16 (0.008%) were hospitalized with severe disease, and only one died, an individual 
over 80 years of age. Another study, analyzing data from Italy, found that only 0.31% of COVID-
recovered patients experienced a reinfection within a year after the initial infection, despite the 
circulation of the Delta variant.12 In summary, the overwhelming conclusion of the pertinent 
scientific literature is that natural immunity is at least as effective against subsequent reinfection 
as even the most effective vaccines. 
 
(an examination of the comparative efficacy of T cell responses to existing variants from patients with natural immunity 
compared to those who received an mRNA vaccine  found that the T cell responses of both recovered COVID patients 
and vaccines were effective at neutralizing mutations  found in SARS-CoV-2 variants). 
10 Abu-Raddad, L. J., Chemaitelly, H., Coyle, P., Malek, J. A., Ahmed, A. A., Mohamoud, Y. A., Younuskunju, 
S., Ayoub, H. H., Kanaani, Z. A., Kuwari, E. A., Butt, A. A., Jeremijenko, A., Kaleeckal, A. H., Latif, A. N., Shaik, 
R. M., Rahim, H. F. A., Nasrallah, G. K., Yassine, H. M., Al Kuwari, M. G., Al Romaihi, H. E., Al-Thani, M. H., 
Al Khal, A., Bertollini, R. (2021). SARS-CoV-2 antibody-positivity protects against reinfection for at least seven 
months with 95% efficacy.  EClinicalMedicine, 35, 1-12.  doi: 10.1016/j.eclinm.2021.100861 (finding that of 129 
reinfections from a cohort of 43,044, only one reinfection was severe, two were moderate, and none were critical or 
fatal); Hall, V. J., Foulkes, S., Charlett, A., Atti, A., Monk, E. J. M., Simmons, R., Wellington, E., Cole, M. J., Saei, 
A., Oguti, B., Munro, K., Wallace, S., Kirwan, P. D., Shroti, M., Vusirikala, A., Rokadiya, S., Kall, M., Zambon, 
M., Ramsay, M., Hopkins, S. (2021). SARS-CoV-2 infection rates of antibody-positive compared with antibody-
negative health-care workers in England: a large, multicentre, prospective cohort study. The Lancet, 397(10283), 
1459-1469.  doi: 10.1016/S0140-6736(21)00675-9 (finding “a 93% lower risk of COVID-19 symptomatic 
infection… [which] show[s] equal or higher protection from natural infection, both for symptomatic and asymptomatic 
infection”); Hanrath, A. T., Payne, B., A., I., & Duncan, C. J. A. (2021). Prior SARS-CoV-2 infection is associated 
with protection against symptomatic reinfection. The Journal of Infection, 82(4), e29-e30.  doi: 
10.1016/j.jinf.2020.12.023 (examined reinfection rates in a cohort of healthcare workers and found “no symptomatic 
reinfections” among those examined and that protection lasted for at least 6 months). 
11 Goldberg, Y., Mandel, M., Woodbridge, Y., Fluss, R., Novikov, I., Yaari, R., Ziv, A., Freedman, L., & Huppert, 
A. (2021). Protection of previous SARS-CoV-2 infection is similar to that of BNT162b2. vaccine protection: A three-
month nationwide experience from Israel. medRxiv, Preprint.  doi: 10.1101/2021.04.20.21255670 
12 Vitale, J., Mumoli, N., Clerici, P., de Paschale, M., Evangelista, I., Cei, M. & Mazzone, A. (2021). Assessment 
of SARS-CoV-2 reinfection 1 year after primary infection in a population in Lombardy, Italy. JAMA Internal 
Medicine, 181(10), 1407-1409. doi: 10.1001/jamainternmed.2021.2959  
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17. Based on such evidence, many scientists have concluded that natural protection against 
severe disease after COVID recovery is likely to be long-lasting. A survey article published on 
June 30, 2021, in the British Medical Journal concluded, “[t]here is reason to think that immunity 
could last for several months or a couple of years, at least, given what we know about other viruses 
and what we have seen so far in terms of antibodies in patients with COVID-19 and in people who 
have been vaccinated.”13 
18. These findings of highly durable natural immunity should not be surprising, as they 
hold for SARS-CoV-1 and other respiratory viruses. According to a paper published in Nature in 
August 2020, 23 patients who had recovered from SARS-CoV-1 still possess CD4 and CD8 T 
cells, 17 years after infection during the 2003 epidemic.14 A Nature paper from 2008 found that 
32 people born in 1915 or earlier still retained some level of immunity against the 1918 flu strain— 
some 90 years later.15 
19. In contrast to the concrete findings regarding the robust durability of natural immunity, 
it is yet unclear in the scientific literature how long-lasting vaccine-induced immunity will be. 
Notably, the researchers argue that they can best surmise the predicted durability of vaccine 
immunity by looking at the expected durability of natural immunity.16 
 
13 Baraniuk, C. (2021). How long does covid-19 immunity last? The British Medical Journal, 373, 1-3. doi: 
10.1136/bmj.n1605 (emphasis added). 
14 Le Bert, N., Tan, A. T., Kunasegaran, K., Tham, C. Y. L., Hafezi, M., Chia, A., Chng, M. H. Y., Lin, M., Tan, 
N., Linster, M., Chia, W. N., Chen, M. I. C., Wang, L. F., Ooi, E. E., Kalimuddin, S., Tambyah, P. A., Low, J. G. H., 
Tan, Y. J. & Bertoletti, A. (2020). SARS-CoV-2-specific T cell immunity in cases of COVID-19 and SARS, and 
uninfected control. Nature, 584, 457-462. doi: 10.1038/s41586-020-2550-z 
15 Yu, X., Tsibane, T., McGraw, P. A., House, F. S., Keefer, C. J., Hicar, M. D., Tumpey, T. M., Pappas, C., 
Perrone, L. A., Martinez, O., Stevens, J., Wilson, I. A., Aguilar, P. V., Altschuler, E. L., Basler, C. F., & Crowe Jr., J. 
E. (2008). Neutralizing antibodies derived from the B cells of 1918 influenza pandemic survivors. Nature, 455, 532-
536. doi: 10.1038/nature07231 
16 Ledford, H. (2021). Six months of COVID vaccines: What 1.7 billion doses have taught scientists. Nature, 
594(7862), 164-167. doi: 10.1038/d41586-021-01505-x (study notes that “Six months is not much time to collect data 
on how durable vaccine responses will be. . . . In the meantime some researchers are looking to natural immunity as a 
guide.”). 
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20. A recent study from Qatar by Chemaitelly and colleagues, which tracked 927,321 
individuals for six months after vaccination, concluded that the Pfizer vaccine’s “induced 
protection against infection appears to wane rapidly after its peak right after the second dose, but 
it persists at a robust level against hospitalization and death for at least six months following the 
second dose.”17  
21. The key figures from the Qatari study are reproduced immediately below. Panel A 
shows that vaccine mediated protection against infection peaks at 72.1% zero to four weeks after 
the second dose, and then declines to 0%, 20 weeks after the second dose. According to this result, 
vaccines only protect against infection (and therefore disease spread) for a short period of time 
after the second dose of the mRNA vaccines.  
 
22. On the other hand, Panel B shows that protection versus severe disease is long lasting 
after vaccination—even though the person will no longer be fully protected against infection and, 
 
17 Chemaitelly, H., Tang, P., Hasan, M. R., Al Mukdad, S., Yassine, H. M., Benslimane, F. M., Khatib, H. A. A., 
Coyle, P., Ayoub, H. H., Kanaani, Z. A., Kuwari, E. A., Jeremijenko, A., Kaleeckal, A. H., Latif, A. N., Shaik, R. M., 
Rahim, H. F. A., Nasrallah, G. K., Kuwari, M. G. A., Romaihi, H. E. A., Abu-Raddad, L. J. (2021). Waning of 
BNT162b2 
vaccine 
protection 
against 
SARS-CoV-2 
infection 
in 
Qatar. 
medRxiv, 
Preprint. 
doi: 
10.1101/2021.08.25.21262584  
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presumably, disease spread. At 20-24 weeks after the second dose, the vaccine remains 95.3% 
efficacious versus severe disease. While it appears to dip after 25 weeks to 71.5% efficacy, the 
confidence interval is so wide that it is consistent with no decrease whatsoever even after 25 weeks.  
 
23. The Qatari study is no outlier. Another recent study documented declining vaccine 
efficacy in the first three months after vaccination against disease transmission in the era of the 
Delta variant.18 Yet another study, conducted in Wisconsin, confirmed that vaccinated individuals 
can shed infectious SARS-CoV-2 viral particles.19 The authors analyzed nasopharyngeal samples 
to check whether patients showed evidence of infectious viral particles. They found that vaccinated 
individuals were at least as likely as unvaccinated individuals to be shedding live virus. They 
concluded: 
 
18 Eyre, D. W., Taylor, D., Purver, M., Chapman, D., Fowler, T., Pouwels, K. B., Walker, A. S. & Peto, T. E. A. 
(2021). The impact of SARS-CoV-2 vaccination on Alpha & Delta variant transmission. medRxiv, Preprint. doi: 
10.1101/2021.09.28.21264260 
19 Riemersma, K. K., Grogan, B. E., Kita-Yarbro, A., Halfmann, P. J., Segaloff, H. E., Kocharian, A., Florek, K. 
R., Westergaard, R., Bateman, A., Jeppson, G. E., Kawaoka, Y., O’Connor, D. H., Friedrich, T. C., & Grande, K. M. 
(2021). 
Shedding 
of 
infectious 
SARS-CoV-2 
despite 
vaccination. 
medRxiv, 
Preprint. 
doi: 
10.1101/2021.07.31.21261387 
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Combined with other studies these data indicate that vaccinated and 
unvaccinated individuals infected with the Delta variant might transmit 
infection. Importantly, we show that infectious SARS-CoV-2 is frequently 
found even in vaccinated persons. 
 
24. In summary, the evidence to date strong suggests that while vaccines—like natural 
immunity—provide protection against severe disease, they, unlike natural immunity, provide only 
short-lasting protection against subsequent infection and disease spread. In short, there is no 
medical or scientific reason to believe that vaccine immunity will prove longer lasting than natural 
immunity, much less that all currently approved vaccines will be expected to prove more durable 
than natural immunity despite their different technological foundations and dosing protocols.  
 
II. 
The Named Plaintiffs Have Naturally Acquired Immunity to COVID-19 
25. I have examined the SARS-CoV-2 specific antibody lab results of Jeanna Norris, Kraig 
Ehm, and D’Ann Rohrer. There is no doubt that, based on recent testing, Ms. Norris, Mr. Ehm, 
and Ms. Rohrer show evidence of positive SARS-CoV-2 antibodies to both the spike protein and 
the nucleocapsid protein. The latter is not found in vaccinated individuals, but rather only in those 
who have previously been infected with the SARS-CoV-2 virus. The existing clinical literature 
overwhelmingly indicates that the protection afforded to the individual and community from 
natural immunity is as effective and durable as the efficacy levels of the most effective vaccines 
to date  (as I discuss in the previous section). From the point of view of Plaintiffs’ personal health, 
there is no good reason that they should be vaccinated. At the very least, the decision should be 
left to Plaintiffs and their doctors without coercion applied by the University. 
 
 
 
 
 
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III. 
Vaccine Side Effects, Though Rare, Do Occur and Can Be Deadly. 
26. Though the COVID vaccines are safe by the standards of many other vaccines approved 
for use in the population, like all medical interventions, they have side effects. In summarizing the 
evidence on vaccine side effects, the CDC lists both common side effects, at least one of which 
occurs in over half of all people who receive the vaccines, as well as deadly side effects that occur 
rarely in demographic subsets of the vaccinated population. 
27. The common side effects include pain and swelling at the vaccination site and fatigue, 
headache, muscle pain, fever, and nausea for a limited time after vaccination.20 Less common but 
severe side effects also include severe and non-severe allergic (anaphylactic) reactions that can 
occur immediately after vaccination, which can typically be treated with an epinephrine injection.21 
Finally, the CDC’s vaccine safety committee has identified rare but deadly side effects, including 
a heightened risk of clotting abnormalities22 in young women after the Johnson & Johnson (J&J) 
vaccination, elevated risks of myocarditis and pericarditis23 in young  people—but especially 
young men—after mRNA vaccination, and higher risk of Guillane-Barre Syndrome24 after the 
J&J vaccine. There is still the possibility of severe side-effects  that have yet to be identified as the 
 
20 Centers for Disease Control and Prevention. (2021, September 30). Possible side effects after getting a 
COVID-19 
vaccine. 
Retrieved 
October 
1, 
2021 
from 
https://www.cdc.gov/coronavirus/2019-
ncov/vaccines/expect/after.html 
21 Centers for Disease Control and Prevention. (2021, August 30). What to do if you have an allergic reaction after 
getting a COVID-19 vaccine. Retrieved October 1, 2021 from  https://www.cdc.gov/coronavirus/2019-
ncov/vaccines/safety/allergic-reaction.html 
22 
Kulldorff, 
M. 
(2021, 
April 
17). 
The 
dangers 
of 
pausing 
the 
J&J 
vaccine. 
The 
Hill. 
https://thehill.com/opinion/healthcare/548817-the-dangers-of-pausing-the-jj-vaccine 
23 National Center for Immunization & Respiratory Diseases, Centers for Disease Control and Prevention. (2021, 
August 23). Clinical considerations: Myocarditis and pericarditis after receipt of mRNA COVID-19 vaccines among 
adolescents and young adults. Retrieved October 1, 2021 from https://www.cdc.gov/vaccines/covid-19/clinical- 
considerations/myocarditis.html 
24 LaFraniere, S. & Weiland, N. (2021, July 12). FDA attaches warning of rare nerve syndrome to Johnson & 
Johnson vaccine. The New York Times.  https://www.nytimes.com/2021/07/12/us/politics/fda-warning-johnson-
johnson-vaccine-nerve-syndrome.html 
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vaccines have been in use in human populations for less than a year. Active investigation to check 
for safety problems is still ongoing. 
28. Though the CDC25 still recommends the vaccines for children 12 years old and up 
despite the evidence of elevated risk of myocarditis, other analysts26 have objected to overly rosy 
assumptions made in the CDC analysis about vaccine side effects. Those analysts suggest that the 
CDC’s recommendation is fragile to minor perturbation in their assumptions. The critical point for 
my analysis—undisputed in the scientific literature—is that the vaccines do have side effects, some 
of which are severe and not all of which are necessarily known now. 
 
IV. 
The Risk of Those Side Effects Is Heightened In Certain Groups & Clinical Data on 
Vaccine Safety and Efficacy are Not Available for Patients with Certain Chronic 
Diseases. 
29. The CDC lists two primary contraindications to COVID vaccination: (1) “severe 
allergic reaction (e.g., anaphylaxis) after a previous dose or to a component of the COVID-19 
vaccine”; and (2) “immediate allergic reaction of any severity to a previous dose or known 
(diagnosed) allergy to a component of the COVID-19 vaccine.”27 Among the inactive ingredients 
of the COVID vaccines, polyethylene glycol (PEG)—which is used in other drugs and vaccines—
is most likely to induce an allergic reaction. In addition to contraindications, the CDC lists several 
precautions to vaccination, including known allergic reactions to polysorbate or PEG or to other 
 
25 Walensky, R. (2021, May 12). CDC director statement on Pfizer’s use of COVID-19 vaccine in adolescents 
age 12 and older. Center for Disease Control and Prevention. Retrieved October 1, 2021 from 
https://www.cdc.gov/media/releases/2021/s0512-advisory-committee-signing.html 
26 Pegden, W. (2021, June 24). Weighing myocarditis cases, ACIP failed to balance the harms vs benefits of 
2nd doses. Medium.  https://medium.com/@wpegden?p=d7d6b3df7cfb 
27 National Center for Immunization & Respiratory Diseases, Centers for Disease Control and Prevention. (2021, 
September 27). Interim clinical considerations for use of COVID-19 vaccines currently approved or authorized in the 
United States. Retrieved October 1, 2021 from https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-
19-vaccines-us.html  
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non-COVID vaccines and injectable therapies. Patients with precautions are encouraged to consult 
with an allergist or immunologist and to conduct an individualized risk assessment by the 
vaccination provider before getting the vaccine 28  
30. Some clinical evidence indicates that those who have recovered from COVID-19 could 
be at a heightened risk of adverse effects compared with those who have never had the virus.29, 30 
This may be because vaccine reactogenicity after the first dose is higher among those with prior 
immunity.31 Despite this evidence, the CDC does not list prior immunity as a contraindication to 
vaccination, though it does recommend waiting 90 days after recovering before vaccination.  
31. Though the CDC recommends the COVID vaccines for all adults, because they are 
novel—available for use in the population for only 9-10 months—there remain open questions 
about their use in special populations because they have not been tested in subgroups of patients 
with particular clinical conditions. For instance, in a comprehensive discussion of the biology of 
 
28 Centers for Disease Control and Prevention. (2021, September 27). Interim clinical considerations for use of 
COVID-19 vaccines currently approved or authorized in the United States: Contraindications and precautions. 
Retrieved Oct. 1, 2021 from https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-
us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-
product%2Fclinical-considerations.html#Contraindications 
29 Mathioudakis, A. G., Ghrew, M., Ustianowski, A., Ahmad, S., Borrow, R., Papavasileiou, L. P., Petrakis, D., 
& Bakerly, N. D. (2021). Self-reported real-world safety and reactogenicity of COVID-19 vaccines: A vaccine 
recipient survey. Life, 11(3), 249. doi: 10.3390/life11030249  
30 Menni, C., Klaser, K., May, A., Polidori, L., Capdevila, J., Louca, P., Sudre, C. H., Nguyen, L. H., Drew, D. 
A., Merino, J., Hu, C., Selvachandran, S., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., 
Modat, M., Joshi, A. D., Spector, T. D. (2021). Vaccine side-effects and SARS-CoV-2 infection after vaccination 
in users of the COVID Symptom Study app in the UK: A prospective observational study. The Lancet Infectious 
Diseases, 21(7), 939-949. doi: 10.1016/S1473-3099(21)00224-3 (finding that “Systemic side-effects were more 
common (1.6 times after the first dose of ChAdOx1 nCoV-19 [i.e., AstraZeneca vaccine] and 2.9 times after the 
first dose of BNT162b2 [i.e., Pfizer/BioNTech vaccine]) among individuals with previous SARS-CoV-2 infection 
than among those without known past infection. Local effects were similarly higher in individuals previously 
infected than in those without known past infection (1.4 times after the first dose of ChAdOx1 nCoV-19 and 1.2 
times after the first dose of BNT162b2).”). 
31 Krammer, F., Srivastava, K., the PARIS team & Simon, V. (2021). Robust spike antibody responses and 
increased reactogenitiy in seropositive individuals after a single dose of SARS-CoV-2 mRNA vaccine. medRxiv, 
Preprint. 
https://www.medrxiv.org/content/10.1101/2021.01.29.21250653v1 
(concluding 
that 
“vaccine 
reactogenicity after the first dose is substantially more pronounced in individuals with pre-existing immunity.” The 
authors note that “quantitative serological assays that measure antibodies to the spike protein could be used to screen 
individuals prior to vaccination,” which would “limit the reactogenicity experienced by COVID-19 survivors.”). 
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immune responses to vaccination (including COVID-19 vaccination) for patients with Multiple 
Sclerosis published in June 2021, Coyle et al. emphasize the lack of high-quality evidence 
available to guide recommendations for MS patients. They point out that three of six medical 
societies that focus on MS patients have failed to make a recommendation on whether MS patients 
should receive the COVID-19 vaccines. They and other authorities32 emphasize the need for 
personalized decision making based on the clinical condition of the MS patient:33 
Currently, three COVID-19 vaccines have been granted emergency use 
authorization in the USA on the basis of promising interim findings of ongoing 
trials. Because analyses of these vaccines in people with MS are not available, 
decisions regarding COVID-19 vaccination and DMT choice should be informed 
by data and expert consensus, and personalized with considerations for disease 
burden, risk of infection, and other factors. 
 
32. The paucity of data on the COVID-19 vaccine on patients with particular conditions is 
not limited to Multiple Sclerosis. Pregnant women were excluded from participating in the 
COVID-19 vaccination trials, consequently only limited randomized trial data are available about 
COVID-19 vaccine safety for that group.34 Though the CDC and obstetrics focused specialty 
organizations nevertheless recommend COVID vaccination for pregnant women, many authors in 
peer reviewed journal articles have pointed to the lack of scientific data regarding vaccine safety 
in this group a problem for clinicians providing accurate advice to pregnant women.35 Given this 
 
32 Ciotti, J. R., Valtcheva, M. V. & Cross, A. H. (2020). Effects of MS disease-modifying therapies on responses 
to vaccinations: A review. Multiple Sclerosis Related Disorders, 45, 1-11.  doi: 10.1016/j.msard.2020.102439 
33 Coyle, P. K., Gocke, A., Vignos, M. & Newsome, S. D. (2021). Vaccine considerations for multiple sclerosis 
in the COVID-19 era. Advances in Therapy, 38(7), 3550-3588. doi:10.1007/s12325-021-01761-3 
34 Rasmussen, S. A., Kelley, C. F., Horton, J. P., & Jamieson, D. J. (2021). Coronavirus disease 2019 (COVID-
19) vaccines and pregnancy: What obstetricians need to know. Obstetrics & Gynecology, 137(3), 408-414. doi: 
10.1097/AOG.0000000000004290 
Erratum 
in: 
Obstetrics 
& 
Gynecology, 
137(5), 
962. 
doi: 
10.1097/AOG.0000000000004379 
35 Holness, N. A., Powell-Young, Y. M., Torres, E., DuBois, S., & Giger, J. N. (2021) Covid-19, pregnancy, and 
vaccinations. Journal of National Black Nurses Association, 32(1), 1-9.. 
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uncertainty, Nicola Volpe and her colleagues36 writing in the Journal of Perinatal Medicine 
explicitly recommend that “Women should discuss with healthcare professionals about the benefits 
and risks of having the vaccine, allowing an informed decision.” In recent months some 
observational studies have shown reassuring results, including that pregnant woman face no 
greater risk of complications during pregnancy or delivery,37 or of spontaneous abortion or 
miscarriage after vaccination.38 Nevertheless, there is still an area of active research where safety 
signals may still emerge. A large French study of vaccine safety in pregnancy expects to report 
complete results in late 2022.39 After a thorough review of mostly reassuring data on the safety of 
the vaccine for pregnant women, Lydia Shook and some of her colleagues at Massachusetts 
General Hospital write that – given the recent introduction of the vaccine into use by pregnant 
women – it may be some time before full safety data become available:40 
Complete pregnancy outcomes data from people vaccinated in the first and early second 
trimesters are not yet available as most of these pregnancies are ongoing. Durability of IgG 
in the blood of neonates born to vaccinated mothers has not yet been defined, nor has 
whether the anti-SARS-CoV-2 IgG generated influences the response to other childhood 
vaccines. Information on postnatal outcomes and offspring development will require long 
term follow-up of children born to individuals who received the vaccine during pregnancy. 
 
 
36 Volpe, N., Luca Schera, G. B., Dall'Asta, A., Di Pasquo, E., & Ghi, T. (2021) COVID-19 in pregnancy: Where 
are we now? Journal of Perinatal Medicine, 49(6), 637-642. doi: 10.1515/jpm-2021-0309. 
37 Theiler, R. N., Wick, M., Mehta, R., Weaver, A. L., Virk, A., & Swift, M. (2021). Pregnancy and birth outcomes 
after SARS-CoV-2 vaccination in pregnancy. American Journal of Obstetrics & Gynecology MFM, 3(6), 100467. doi: 
10.1016/j.ajogmf.2021.100467 Online ahead of print.  
38 Kharbanda, E. O., Haapala, J., DeSilva, M., Vazquez-Benitez, Vesco, K. K., Naleway, A. L., & Lipkind, H. S. 
(2021). Spontaneous abortion following COVID-19 vaccination during pregnancy. JAMA, e2115494. Online ahead 
of print. doi:10.1001/jama.2021.15494 
39 Cottin, J., Benevent, J., Khettar, S., & Lacroix, I. (2021). COVID-19 vaccines and pregnancy: What do we 
know? Therapie, 76(4), 373-374. doi: 10.1016/j.therap.2021.05.011 
40 Shook, L. L., Fallah, P. N., Silberman, J. N., & Edlow, A. G. (2021) COVID-19 vaccination in pregnancy and 
lactation: Current research and gaps in understanding. Frontiers in Cellular and Infection Microbiology, 11, 735394. 
doi: 10.3389/fcimb.2021.735394 
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33. There are also patients with particular genetic conditions where vaccine safety data are 
not adequate. For instance, for patients with alpha-1 antitrypsin deficiency (AATD), an inherited 
disorder that predisposes a patient to enzymatic tissue injuries and inflammation—especially in 
the lungs— there are no clinical data whatsoever regarding the safety and efficacy of the COVID-
19 vaccines. Writing in Lancet Respiratory Medicine, Yang and Zhao hypothesize “individuals 
with AATD might derive limited benefit from the current COVID-19 vaccines.” They note that 
“even though vaccination has been prioritised to more vulnerable populations (such as people with 
AATD), individuals with AATD are usually not included in clinical trials (as reported 
in ClinicalTrials.gov), and thus the effectiveness and adverse event profile of vaccination in this 
population are unknown.”41 The same can be said for other patients with many other chronic 
diseases, for whom the decision whether to vaccinate should be an individual decision made in 
consultation with their physicians, rather than coerced by a firm or the government. 
V. 
Asymptomatic Disease Spread is Rare. 
34. In this section, I discuss the evidence regarding the asymptomatic transmission of 
disease. This is important because if asymptomatic disease spread is rare, MSU can keep its 
campus safe from COVID disease spread by the simple expedient of requiring those who have not 
been vaccinated (and even those who have been) to report daily through an online app whether 
they are experiencing symptoms consistent with COVID-19. Those who are experiencing 
symptoms would be asked to stay at home from work or class and get tested; returning to campus 
only if the test is negative.  
 
41 Yang, C. & Zhao, H. (2021) COVID-19 vaccination in patients with α1-antitrypsin deficiency. The Lancet, 
Respiratory Medicine, 9(8), 818-820. doi:10.1016/S2213-2600(21)00271-X 
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35. The best evidence on how frequently asymptomatic disease spread occurs comes from 
a large meta-analysis of 54 studies from around the world of within-household spread of the 
virus—that is, from an infected person to someone else living in the same home (Madewell et al. 
2020). This study represents the most comprehensive survey of the vast empirical literature on 
asymptomatic spread. At home, of course, none of the safeguards often recommended in public 
spaces outside of home (such as masking and social distancing) are typically applied. Because the 
study focuses on a single setting (household transmission), it is not subject to the same problems 
that other studies on this topic might have. In particular, by focusing on a homogenous setting 
where few safeguards exist, the estimate represents an upper bound on the frequency that someone 
positive for the virus but with no symptoms (and hence either pre-symptomatic or asymptomatic) 
may spread the virus to close contacts. The primary result is that symptomatic patients passed on 
the disease to household members in 18% of instances. In comparison, those infected but without 
symptoms (asymptomatic and pre-symptomatic patients) passed on the infection to household 
members in only 0.7% of instances.42  
36. There is some additional evidence on how frequently asymptomatic disease spread 
occurs. A large study of 10 million residents of Wuhan, China, all tested for the presence of the 
virus, found a total of 300 cases, all asymptomatic. A comprehensive contact tracing effort 
identified 1,174 close contacts of these patients, none of whom tested positive for the virus.43 This 
is consistent with a vanishingly low level of asymptomatic spread of the disease. Given the late 
 
42 Madewell, Z. J., Yang, Y., Longini, I. M., Halloran, M. E. & Dean, N. E. (2020). Household transmission 
of SARS-CoV-2: A systematic review and meta-analysis. JAMA Network Open, 3(12), 1-17. 
doi:10.1001/jamanetworkopen.2020.31756 
43 Cao, S., Gan, Y., Wang, C., Bachmann, M., Wei, S., Gong, J., Huang, Y., Wang, T., Li, L., Lu, K., Jiang, H., 
Gong, Y., Xu, H., Shen, X., Tian, Q., Lv, C., Song, F., Yin, X. & Lu, Z. (2020). Post-lockdown SARS-CoV-2 nucleic 
acid screening in nearly ten million residents of Wuhan, China. Nature Communications, 11(1), 5917.  doi: 
10.1038/s41467-020-19802-w 
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date of the study relative to the date of the large first wave of infections in Wuhan, it is likely that 
none of the 300 asymptomatic cases were likely ever to develop symptoms.  A separate, smaller 
meta-analysis similarly found that asymptomatic patients are much less likely to infect others than 
symptomatic patients.44  
37. By contrast with asymptomatic patients, symptomatic patients are very likely to infect 
others with the virus during extended interactions, especially in the initial period after they develop 
symptoms. A careful review of 79 studies on the infectivity of COVID-19 patients found that even 
symptomatic patients are infectious for only the first eight days after symptom onset, with no 
evidence of live virus detected beyond day nine of illness.45  
38. Much of the support for the idea that asymptomatic disease spread is common comes 
from theoretical modeling work from earlier in the epidemic (including some of my own published 
research46), predicting some level of asymptomatic disease spread. However, this sort of modeling 
work does not represent actual evidence that asymptomatic spread is common in the real world, 
since they rely on many modeling assumptions that are impossible to check.  
39. There is at least one prominent real-world study that some have used to argue that 
asymptomatic disease spread is common. A meta-analytic study by Qiu et al. (2021) distinguishes 
the likelihood of disease spread by a pre-symptomatic individual from the likelihood of spread by 
 
44 Buitrago-Garcia, D., Egli-Gany, D., Counotte, M. J., Hossmann, S., Imeri, H., Ipekci, A. M., Salanti, G. & 
Low, N. (2020). Occurrence and transmission potential of asymptomatic and presymptomatic SARS-CoV-2 
infections: A living systematic review and meta-analysis. PLOS Medicine, 17(9), e1003346. doi: 
10.1371/journal.pmed.1003346 
45 Cevik, M., Tate, M., Lloyd, O., Maraolo, A. E., Schafers, J. & Ho, A. (2021). SARS-CoV-2, SARS-CoV, and 
MERS-CoV viral load dynamics, duration of viral shedding, and infectiousness: A systematic review and meta-
analysis. The Lancet, Microbe, 2(1), e13-e22. doi: 10.1016/S2666-5247(20)30172-5 
46 Peirlinck, M., Linka, K., Costabal, F. S., Bhattacharya, J., Bendavid, E., Ioannidis, J. P. A. & Kuhl, E. (2020). 
Visualizing the invisible: The effect of asymptotic transmission on the outbreak dynamics of COVID-19. Computer 
Methods in Applied Mechanics and Engineering, 372(1), 113140. doi:  10.1016/j.cma.2020.113410 
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an asymptomatic individual who never develops symptoms.47  A primary finding of this study is 
that, while an asymptomatic individual who never develops symptoms is exceedingly unlikely to 
spread the disease, individuals who are not symptomatic now but will eventually develop 
symptoms are efficient at infecting others during their pre-symptomatic state.  
40. Distinguishing between an infected individual who will eventually develop symptoms 
and an infected individual who will never develop symptoms is difficult without the passage of 
time. Infected individuals who will develop symptoms tend to do so within a very short interval 
(two to three days) after first becoming infected. Meanwhile, infected individuals who never 
develop symptoms may test positive with the PCR test for the virus for an extended period. These 
two groups of observationally identical individuals are mixed in the population in some unknown 
frequency that may change over time. Given this information constraint, from a policy point of 
view, the relevant question is how likely it is that an infected individual without symptoms 
(whether pre-symptomatic or purely asymptomatic) will spread the disease to close contacts. The 
Madewell et al. (2020) study provides an answer (less than 0.7% secondary attack rate in 
household settings), while the Qiu et al. (2021) study does not. Additionally, unlike the Madewell 
et al. (2020) study, the Qiu et al. (2021) study does not concentrate its focus on a homogenous 
environment (households), which makes the results it reports harder to interpret.  
41. In summary, asymptomatic individuals are an order of magnitude less likely to infect 
others than symptomatic individuals, even in intimate settings such as people living in the same 
household where people are much less likely to follow social distancing and masking practices 
that they follow outside the household. Spread of the disease in less intimate settings by 
 
47 Qiu, X., Nergiz, A. I., Maraolo, A. E., Bogoch, I. I., Low, N. & Cevik, M. (2021). The role of asymptomatic 
and pre-symptomatic infection in SARS-CoV-2 transmission-A living systematic review. Clinical Microbiology and 
Infection, 27(4), 511-519. doi: 10.1016/j.cmi.2021.01.011 
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asymptomatic individuals—including in the context of the MSU campus environment—is likely 
to be even less likely than in the household.  
VI. 
There Are Multiple Safe Alternatives to Indefinite Leave or Termination that Can Be 
Offered to MSU Employees. 
42. Can MSU keep those on campus safe if it does not mandate that all its employees (and 
students) be vaccinated? The answer is a definitive yes.  
43. First and most obviously, MSU could adopt a robust sick policy, requiring that those 
who have not been vaccinated and who show symptoms consistent with COVID-19 infection stay 
at home from work, returning to work only once they have had a negative COVID-19 PCR or 
antigen test result. This could be implemented, for instance, by requiring workers to complete a 
symptom self-check each day before coming to work. MSU would provide employees and students 
with a supply of inexpensive rapid antigen tests, which are easy to self-administer at home, provide 
results within 30 minutes, and are highly accurate for detecting whether a patient is infectious.48, 
49  A large number of lateral flow antigen tests have received Emergency Use Authorization (EUA) 
by the US Food and Drug Administration.50 Alternatively, MSU could require that any 
unvaccinated members of its campus obtain those tests themselves to keep its own costs down. 
Employees who report COVID-19 like symptoms would be asked to send a picture of their positive 
test result to their manager by phone or email to verify their result.51 A system that required the 
 
48 Surasi, K., Cummings, K. J., Hanson, C., Morris, M. K., Salas, M., Seftel, D., Ortiz, L., Thilakaratne, R., 
Stainken, C. & Wadford, D. A. (2021). Effectiveness of Abbott BinaxNOW rapid antigen test for detection of SARS-
CoV-2 infections in outbreak among horse racetrack workers, California, USA. Emerging Infectious Diseases, 27(11).  
49 Homza, M., Zelena, H., Janosek, J., Tomaskova, H., Jezo, E., Kloudova, A., Mrazek, J., Svagera, Z. & Pymula, 
R. (2021). Covid-19 antigen testing: Better than we know? A test accuracy study. Infectious Diseases, 53(9), 661-668. 
doi: 10.1080/23744235.2021.1914857 
50 US FDA. (2021) In-Vitro Diagnostics EUA – Antigen Diagnostic Tests for SARS-CoV-2. Oct. 4, 2021. 
https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-
devices/in-vitro-diagnostics-euas-antigen-diagnostic-tests-sars-cov-2  Accessed Oct. 10, 2021 
 
51 Indeed, if United’s goal is really to prevent the spread of COVID-19 as much as reasonably possible, symptom 
checking should be required of all workers, whether vaccinated or not, since the evidence shows that vaccination 
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few employees who seek the vaccine exemption to provide this information to their manager each 
day before coming to work would be inexpensive – no online reporting system would be necessary. 
44. For this symptom checking policy to be effective in reducing the risk of disease spread, 
it must be the case that symptomatic workers are substantially more likely to infect others than 
workers who are infected (that is, have evidence of the virus in the nasopharynx), but who have 
no symptoms. Fortunately, as we have seen in the previous section, the best empirical evidence 
shows that the probability that an asymptomatic individual will spread the disease is very low. And 
because the overwhelming majority of MSU employees will themselves be vaccinated, they face 
even less risk from any of their asymptomatic, unvaccinated coworkers who receive an 
accommodation from MSU for religious or medical reasons (including on the basis of naturally 
acquired immunity) of developing severe COVID symptoms. 
45. Second, MSU could implement a program of weekly PCR or antigen testing as a 
condition of an employee’s receiving an exemption.    Many other organizations have implemented 
a testing regimen like this for all employees, including my home institution, Stanford University. 
Workers receiving an exemption could take the test in the workplace—there are versions of the 
test available that can be self-administered. Or workers could be required to purchase and take the 
test at home.52   
46. Third, MSU could simply exempt from its vaccine requirement all employees who 
legitimately claim an exemption and have recovered from COVID infection. The evidence 
provided in this declaration shows that such employees pose at least as little—and likely less—
 
does not eliminate the possibility of infection and may provide less protection versus infection than immunity 
induced by prior COVID infection. 
52 Indeed, the safest option would be for both vaccinated and unvaccinated workers to be required to provide a 
weekly test, since both can have asymptomatic SARS-CoV-2 infections. 
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risk of spreading the SARS-CoV-2 virus than fully vaccinated workers who are not among the set 
of COVID-recovered patients.  
47. While it is true that those who have recovered from COVID could incrementally reduce 
the infection risk they pose to other employees by also receiving the vaccine, it would make no 
sense for MSU to make this a requirement.  For one thing, the incremental safety benefit of such 
a requirement would be vanishingly small. A study analyzing 738 patients in Kentucky and 
published in the CDC’s journal (MMWR), estimated that the odds that COVID-recovered patients 
who are vaccinated are 2.34 [95% CI: 1.58-3.47] times lower for reinfection than COVID-
recovered patients who are not vaccinated.53 However, this reduction in the relative risk of 
reinfection represents a vanishingly small absolute risk reduction. Recall the study of Italian 
COVID-recovered patients that I cite above reported a reinfection rate of 0.3%, or 3 out of 1,000 
after one year.54 If the Kentucky study is right, vaccinating COVID recovered patients prevents on 
the order 2 infections out of a 1,000 people. This reduction can easily be replicated and improved 
upon without forced vaccination but with the symptom checking and regular testing solutions I 
suggest. 
48. Moreover, the proper baseline for assessing the reasonableness of an exemption policy 
is not what kind of policy would produce the maximum reduction in risk, but rather what exemption 
options would reduce the risk posed by those receiving an exemption to a level below that posed 
by those complying with MSU’s vaccination requirement.  After all, MSUU is willing to tolerate 
the risk of infection posed by those who have received the vaccine—a risk that increases 
 
53 Cavanaugh AM, Spicer KB, Thoroughman D, Glick C, Winter K. Reduced Risk of Reinfection with SARS-CoV-2 After 
COVID-19 Vaccination — Kentucky, May–June 2021. MMWR Morb Mortal Wkly Rep 2021;70:1081-1083. DOI: 
http://dx.doi.org/10.15585/mmwr.mm7032e1 
54 Vitale, J., Mumoli, N., Clerici, P., de Paschale, M., Evangelista, I., Cei, M. & Mazzone, A. (2021). Assessment of 
SARS-CoV-2 reinfection 1 year after primary infection in a population in Lombardy, Italy. JAMA Internal 
Medicine, 181(10), 1407-1409. doi: 10.1001/jamainternmed.2021.2959 
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substantially a few months after vaccination, or those who have received vaccines such as the 
Sinovac vaccine, for which no phase 3 randomized clinical trial study has been published (a 
Sinovac randomized trial is due to be completed in February 2022.55  If the objective were to 
reduce infection risk as much as humanly possible, MSU would have to require its vaccinated 
employees to find a way to contract COVID (and stay home until they recover)—since the 
combination of a vaccination and a prior COVID reduces infection risk compared to either alone.  
But MSU could not reasonably impose such a requirement, since an actual COVID infection would 
pose additional health risks to those who have been vaccinated.  By the same risk/benefit logic—
in light of the health risks posed by the vaccine itself—MSU cannot reasonably require those 
seeking an exemption who have recovered from COVID to also be vaccinated. 
 
VII. 
Variants Do Not Alter the Conclusion that Accommodations Can Be Allowed Without 
Risk to Public Safety. 
49. Since its spread through the human population, the SARS-CoV-2 virus—an RNA 
virus—has been mutating, including some forms that are likely more transmissible than the 
original wild-type virus that emerged from Wuhan, China, in 2019. As of the date of this 
declaration, the Delta variant is the dominant form of the SARS-CoV-2 virus worldwide. The virus 
will continue to mutate as it continues to spread. However, the possibility of such a mutation does 
not alter the conclusion that accommodations can be allowed without risk to public safety. 
50. For one thing, the first two accommodations discussed above would be equally 
effective against variants as they are against the original Wuhan version.  That is because all 
variants to arise thus far produce symptoms that can be checked for, and can be identified through 
standard COVID testing.  So regular symptom-checking and/or testing for those receiving medical 
 
55 US National Library of Medicine. Clinical Trials.gov. An Effectiveness Study of the Sinovac’s Adsorbed COVID-19 
(Inactivated) Vaccine (Projeto S). https://clinicaltrials.gov/ct2/show/NCT04747821. Accessed 10/18/2021 
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or religious accommodations.   
51. Variants likewise do not affect the reasonableness of the COVID-recovery alternative 
discussed above.  The key point is that the mutant variants do not escape the immunity provided 
by prior infection with the wild-type virus or vaccination.56, 57, 58 This is true of the Delta variant 
as well. In a study of a large population of patients in Israel, vaccinated people who had not been 
previously infected were 13 times more likely to experience a breakthrough infection with the 
Delta variant than patients who had recovered from COVID.59 Although reinfection can occur, 
people who have been previously infected by the virus are unlikely to have a severe outcome 
(hospitalization or death) after exposure to a variant virus (see section I above for citations). A 
variant circulating in the population thus poses little additional risk of excess mortality due to viral 
infection. 
52. The dissemination of vaccines that protect against hospitalizations and deaths upon 
COVID-19 infection throughout the older population in the United States has partially  decoupled 
the growth in COVID-19 cases from COVID-19 mortality. Vaccinated people can still be infected 
but much less commonly have severe symptoms in response to infection. Throughout last year, a 
rise in cases was inevitably accompanied by an increase in deaths with a two-to-three-week lag. 
 
56 Tarke, A., Sidney, J., Methot, N., Yu, E. D., Zhang, Y., Dan, J. M., Goodwin, B., Rubiro, P., Sutherland, A., 
Wang, E., Frazier, A., Ramirez, S. I., Rawlings, S. A., Smith, D. M., da Silva Antunes, R., Peters, B., Scheuermann, 
R. H., Weiskopf, D., Crotty, S., Grifoni, A. & Sette, A. (2021).  Impact of SARS-CoV-2 variants on the total CD4+ 
and CD8+ T cell reactivity in infected or vaccinated individuals, Cell Reports Medicine 2, 100355. 
57 Wu, K., Werner, A. P., Moliva, J. I., Koch, M., Choi, A., Stewart-Jones, G. B. E., Bennett, H., Boyoglu-
Barnum, S., Shi, W., Graham, B. S., Carfi, A., Corbett, K. S., Seder, R. A. & Edwards, D. K. (2021). mRNA-1273 
vaccine induces neutralizing antibodies against spike mutants from global SARS-CoV-2 variants. bioRxiv, Preprint. 
doi: 10.1101/2021.01.25.427948 
58 Redd, A. D., Nardin, A., Kared, H., Bloch, E. M., Pekosz, A., Laeyendecker, O., Abel, B., Fehlings, M., Quinn, 
T. C. & Tobian, A. A. (2021). CD8+ T-cell responses in COVID-19 convalescent individuals target conserved epitopes 
from multiple prominent SARS-CoV-2 circulating variants. Open Forum Infectious Diseases 8(7), ofab143.  
59 Gazit, S., Shlezinger, R., Perez, G., Lotan, R., Peretz, A., Ben-Tov, A., Cohen, D., Muhsen, K., Chodick, G. & 
Patalon, T. (2021). Comparing SARS-CoV-2 natural immunity to vaccine-induced immunity: Reinfections versus 
breakthrough infections. medRxiv, Preprint. doi: 10.1101/2021.08.24.21262415 
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However, during this most recent wave, in Sweden and the U.K., where vaccines have been 
provided to a large portion of the vulnerable elderly population and more, there have been 
“relatively few hospitalisations and deaths” in those countries.60 Because of the success of the 
American vaccination effort among the vulnerable elderly, COVID-19 cases and COVID-19 
deaths are at least partially decoupled, so the public danger from the continuing spread of COVID-
19 disease is less than it was last year when the vaccine was not available. 
VIII. The Presence of Lingering Post-Viral Infection Symptoms in a Subset of Recovered 
COVID Patients (“Long COVID”) Does Not Alter the Conclusion that 
Accommodations Pose No Threat to Public Safety.  
53. Some analysts and politicians have used the possibility that a fraction of patients who 
recover from COVID infection will experience lingering symptoms to justify unyielding vaccine 
mandates. Long COVID, as this phenomenon is called, includes a complex set of clinical outcomes 
with a poorly understood link to acute COVID infection.61 One cross-sectional study found that 
about 30% of recovered COVID patients reported at least one symptom months after recovery, 
with fatigue and anosmia (loss of sense of smell) by far the most common.62 A separate study with 
a more convincing longitudinal methodology, by contrast, concluded that only 2.3% of patients 
experienced such symptoms three months after recovery.63 Patients who suffered a more severe 
 
60 Bhattacharya, J., Kulldorff, M. & Gupta, S. (2021, July 12). Sweden’s lessons for the UK’s third wave. The 
Spectator. https://www.spectator.co.uk/article/sweden-shows-that-the-uk-s-third-wave-won-t-sting 
61 Nalbandian, A., Sehgal, K., Gupta, A., Madhavan, M. V., McGroder, C., Stevens, J. S., Cook, J. R., Nordvig, 
A. S., Shalev, D., Sehrawat, T. S., Ahluwalia, N., Bikdeli, B., Dietz, D., Der-Nigoghossian, C., Liyanage-Don, N., 
Rosner, G. F., Bernstein, E. J., Mohan, S., Beckley, A. A. & Wan, E. Y. (2021). Post-acute COVID-19 syndrome. 
Nature Medicine, 27(4), 601-615.  doi: 10.1038/s41591-021-01283-z 
62 Logue, J. K., Franko, N. M., McCulloch, D. J., McDonald, D., Magedson, A., Wolf, C. R., & Chu, H. Y. (2021). 
Sequelae in adults at 6 months after COVID-19 infection. JAMA Network Open, 4(2), e210830.  doi: 
10.1001/jamanetworkopen.2021.0830 
63 Sudre, C. H., Murray, B., Varsavsky, T., Graham, M. S., Penfold, R. S., Bowyer, R. C., Pujol, J. C., Klaser, K., 
Antonelli, M., Canas, L. S., Molteni, E., Modat, M., Cardoso, M. J., May, A., Ganesh, S., Davies, R., Nguyen, L. H., 
Drew, D. A., Astley, C. M., Steves, C. J. (2021). Attributes and predictors of long COVID. Nature Medicine, 27(4), 
626-631. doi: 10.1038/s41591-021-01292-y 
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acute course of COVID, including hospitalization, were more  likely to report lingering symptoms 
after recovery.64 A study of children who recovered from COVID found the same rate of long 
COVID symptoms as a control group of children who had no serological evidence of prior COVID 
infection.65 Some analysts have noted the similarity between “long COVID” symptoms and other 
functional somatic syndromes that sometimes occur after other viral infections and other triggers 
(and sometimes with no identifiable etiology).66 
54. To summarize, as with other viruses, long COVID symptoms occur in a minority of 
patients who recover from COVID and pose a real burden on patients who suffer from it. However, 
this fact does not alter the logic of my point about accommodations. On the contrary. After 
suffering through a COVID infection, with or without long COVID, such individuals should not be 
forced to also endure common, but mild, vaccine adverse reactions or risk rare—but serious—
adverse reactions. Moreover, the successful vaccine rollout in the United States—where every 
teenager and adult now have free access to the vaccines—addresses the problem of long COVID, 
just as it addresses COVID-associated mortality. 
IX. 
The CDC’s Recommendation for Vaccination of Recovered COVID Patients Applies 
with Equal Force to Those Who Have Been Previously Vaccinated, Whose Protection 
Against Infection Wanes Within a Few Months After Vaccination. 
55. The CDC, in the Frequently Asked Questions (FAQ) section of its website encouraging 
 
64 Arnold, D. T., Hamilton, F. W., Milne, A., Morley, A. J., Viner, J., Attwood, M., Noel, A., Gunning, S., Hatrick, 
J., Hamilton, S., Elvers, K. T., Hyams, C., Bibby, A., Moran, E., Adamali, H. I., Dodd, J. W., Maskell, N. A., Barratt, 
S. L. (2021). Patient outcomes after hospitalisation with COVID-19 and implications for follow-up: Results from a 
prospective UK cohort. Thorax, 76, 399-401. doi: 10.1136/thoraxjnl-2020-216086 
65 Radtke, T., Ulyte, A.,  Puhan, M. A. & Kriemler, S. (2021). Long-term symptoms after SARS-CoV-2 infection 
in school children: Population-based cohort with 6-months follow-up. JAMA, 326(9), 869-871. doi: 
10.1001/jama.2021.11880  
66 Ballering, A., Olde Hartman, T. & Rosmalen, J. (2021). Long COVID-19, persistent somatic symptoms and 
social  stigmatization. Journal of Epidemiology and Community Health, 75, 603-604.  doi: 10.1136/jech-2021-216643 
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vaccination, provides the following advice to previously recovered patients:67 
Yes, you should be vaccinated regardless of whether you already had COVID-
19. That’s because experts do not yet know how long you are protected from 
getting sick again after recovering from COVID-19. Even if you have already 
recovered from COVID-19, it is possible—although rare—that you could be 
infected with the virus that causes COVID-19 again. Studies have shown that 
vaccination provides a strong boost in protection in people who have recovered 
from COVID-19. Learn more about why getting vaccinated is a safer way to build 
protection than getting infected. 
 
56. The text of this advice by the CDC does not address any of the scientific evidence 
included here about the lack of necessity for recovered COVID patients to be vaccinated. While it 
is true that I do not know how long natural immunity after recovery lasts, the immunological 
evidence to date suggests that protection against disease will last for years.68 Uncertainty over the 
longevity of immunity after recovery is a specious reason for not exempting COVID-recovered 
patients from vaccination mandates, since the same can be said about vaccine mediated immunity. 
I do not know how long it will last either, and there is no reason to believe it provides longer lasting 
or more complete immunity than recovery from COVID. 
57. Similarly, just as reinfections are possible though rare after COVID recovery, 
breakthrough infections are possible after vaccination, as the CDC’s team investigating vaccine 
breakthrough infections itself recognizes.69 On the same CDC FAQ webpage I cite above,70 the 
 
67 Centers for Disease Control and Prevention. (2021, September 28). Frequently asked questions about COVID-
19 vaccination. Retrieved October 1, 2019 from  https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html 
68 Patel, N. V. (2021, January 6). Covid-19 immunity likely lasts for years. MIT Technology Review. 
https://www.technologyreview.com/2021/01/06/1015822/covid-19-immunity-likely-lasts-for-years/ 
69 CDC COVID-19 Vaccine Breakthrough Case Investigations Team. (2021). COVID-19 Vaccine 
Breakthrough  Infections Reported to CDC — United States, January 1–April 30, 2021. Morbidity and Mortality 
Weekly Report (MMWR), 70(21), 792-793. doi: http://dx.doi.org/10.15585/mmwr.mm7021e3  
70 Centers for Disease Control and Prevention. (2021, September 28). Frequently asked questions about COVID-
19 vaccination. Retrieved October 1, 2021 from  https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html 
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CDC writes about vaccine mediated immunity, “We don’t know how long protection lasts for 
those who are vaccinated.” 
58. The CDC’s main concern in this FAQ seems to be to help people understand that it is 
safer to attain immunity against SARS-CoV-2 infection via vaccination rather than via infection. 
This is a point not in dispute. Rather, the question is whether someone who already has been 
infected and recovered will benefit on net from the additional protection provided by vaccination. 
On this point, the CDC’s statement in the FAQ is irrelevant.  Here again, the possibility of 
reinfection does not alter the conclusion that, especially for those who have already recovered from 
COVID, accommodations can be allowed without threatening public safety. 
X. 
Conclusion 
59. A fundamental ethical principle guiding the practice of medicine is that any medical 
intervention, whether surgical, pharmacological, or a vaccine, should be recommended and 
undertaken only if it is deemed medically necessary. Any medical procedure, including 
vaccination, involves risk. No medical procedure is 100% safe, especially those involving a new 
vaccine, which by definition has not been studied for long-term adverse side effects. For this reason, 
it is a fundamental principle of medical ethics that the risks of the procedure be balanced against 
the potential benefits. 
60. As I established earlier, based on the scientific evidence to date, those who have 
recovered from a SARS-CoV-2 infection possess immunity as robust and durable (or more) as that 
acquired  through vaccination. The existing clinical literature overwhelmingly indicates that the 
protection afforded to the individual and community from natural immunity is as effective and 
durable as the efficacy levels of the most effective vaccines to date. There is no good reason for 
those who have such protection and who have sincere medical or religious objections to be 
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vaccinated. At the very least, the decision should be left to them, in conjunction with their doctors, 
and without coercion from their employers. 
61. In sum, based on my analysis of the existing medical and scientific literature, any 
exemption policy that does not recognize natural immunity is irrational, arbitrary, and 
counterproductive to community health.71 
62. Indeed, now that every American adult and teenager has free access to the vaccines, 
the case for a vaccine mandate is weaker than it once was. There is no good public health case for 
United Airlines to require proof of vaccination for employees who have recovered from COVID-
19 and have a sincere medical or religious objection to vaccination. Since the successful 
vaccination campaign already protects the vulnerable population, the unvaccinated—especially 
recovered COVID patients—pose a vanishingly small threat to the vaccinated. They are protected 
by an effective vaccine that dramatically reduces the likelihood of hospitalization or death after 
infections to near zero. At the same time, natural immunity provides benefits that are at least as 
strong and may well be stronger than those from vaccines. 
63. In conclusion, the emerging evidence from the medical literature finds that COVID-
recovered patients have robust and long lasting immunity against SARS-CoV-2 reinfection; that 
this immunity against infection is better than vaccinated patients who have never had COVID; that 
the vaccines—though safe for most people—do sometimes cause known severe side effects; that 
for patients with particular chronic conditions, including Multiple Sclerosis, the data on the safety 
and efficacy of the vaccine is still uncertain; and finally, that there exist inexpensive safe 
 
71 Bhattacharya, J., Gupta, S. & Kulldorff, M. (2021, June 4). The beauty of vaccines and natural immunity. 
Smerconish 
Newsletter. 
https://www.smerconish.com/exclusive-content/the-beauty-of-vaccines-and-natural-
immunity 
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1313   Filed 11/05/21   Page 65 of 92

 
31 
 
accommodations that MSU can adopt which would protect both employees and customers against 
SARS-CoV-2 infection without terminating unvaccinated employees. 
64. I declare under penalty of perjury under the laws of the United States of America that, 
to the best of my knowledge, the foregoing is true and correct this 18th day of October, 2021, at 
Stanford, California. 
Respectfully submitted, 
 
 
_____________________________ 
Dr. Jay Bhattacharya, MD, Ph.D. 
Professor of Health Policy 
Stanford University 
 
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1314   Filed 11/05/21   Page 66 of 92

EXHIBIT D 
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Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1316   Filed 11/05/21   Page 68 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1317   Filed 11/05/21   Page 69 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1318   Filed 11/05/21   Page 70 of 92

EXHIBIT E 
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Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1320   Filed 11/05/21   Page 72 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1321   Filed 11/05/21   Page 73 of 92

Renee Gagnier
Digitally signed by Renee Gagnier 
Date: 2021.11.03 13:17:56 -04'00'
11/3/2021
Kraig Ehm
11/4/21
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1322   Filed 11/05/21   Page 74 of 92

EXHIBIT F 
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1 
 
Declaration of D’Ann Rohrer 
I hereby declare under penalty of perjury under the laws of the United States of America that 
the foregoing is true and correct: 
1. 
I am a 51-year-old Extension Educator at MSU (“MSU”), a public research 
university in East Lansing, Michigan, where I have been employed for over six (6) years.   
2. 
My duties entail: statewide MSU Extension Educator in the areas of Global Cultural 
Education; International Exchange Coordinator; Youth and Teen Mental Health First Aid 
Facilitator; Philanthropy Educator; and Racial Dialogue Facilitator.  I am part of the Leadership, 
Civic, and Cultural Engagement work team. I work directly with adults, youths and teens across 
the state.  I have facilitated virtual and in-person trainings in the above areas, and have coordinated 
service agreements with outside organizations.   
3. 
I was diagnosed with COVID-19 in August of 2021, and an antibody test from 
October 4, 2021 confirms that I have naturally acquired immunity to the virus. 
4. 
I was notified of the vaccine requirement via email for the first time on July 30, 
2021.  The email did not contain significant detail about the vaccine mandate, only announcing 
that all students and employees must be immunized by August 31, 2021 unless they receive a 
religious or medical exemption.   
5. 
On August 5, 2021, the University posted a more detailed Directive on its website, 
including the circumstances in which medical and religious exemptions will be granted (natural 
immunity does not qualify) and applying the Directive even to employees who only work remotely.  
6. 
I have been placed on unpaid leave due to failure to comply with the Directive. 
7. 
I contacted the New Civil Liberties Alliance (“NCLA”) in an attempt to secure 
representation to challenge MSU’s Directive as it applied to me.  
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1324   Filed 11/05/21   Page 76 of 92

2 
 
8. 
NCLA agreed to represent me on October 21, 2021, and I signed an engagement 
letter on that date. 
9. 
I believe this Directive violates our duty not to discriminate.  My work team teaches 
youth voice and how to stand up for what we feel is right and constitutional.  I will practice what 
I teach.  Due to the directive, I am on unpaid leave which causes a financial burden on my family.  
I had planned to retire from MSU in approximately ten years.   
10. 
As a Mental Health First Aid Facilitator I have utilized the National Council for 
Wellbeing self-care plan to make sure I am able to continue to be strong through this uncomfortable 
experience.  I am a healthy person, I was a collegiate athlete, All-American, attended an Olympic 
Training camp as well as eat healthy and regularly exercise.  I monitor my vitamin intake and 
avoid unhealthy choices.  I do not wish to take a vaccine that is medically unnecessary to me.   
11. 
I am prepared, ready willing and able to represent a class of similarly situated 
employees of MSU and I can direct and aid the attorneys of NCLA in the prosecution of this suit 
on my behalf and that of the class. 
 
Executed on: 
 
 
 
_________________________________________________ 
 
 
D’Ann Rohrer 
 
 
 
 
__________________________ 
 
 
Date 
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1325   Filed 11/05/21   Page 77 of 92

EXHIBIT G 
Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1326   Filed 11/05/21   Page 78 of 92

MSU Faculty, Staff and Students, 
Since I arrived at MSU and throughout the pandemic, I have continued to place the health 
and safety of our students, faculty and staff at the forefront of all decisions. My priority has 
been to protect our campus and surrounding communities as we respond to the COVID-19 
pandemic, using data and science-based information to inform every decision. 
I have been a constant advocate for the COVID-19 vaccine as the best defense against the 
spread of the disease and the clearest path to the resumption of our on-campus living and 
learning. I am encouraged that the response to the vaccine has been largely positive, and 
members of our community are making the choice to protect themselves and others. 
However, the yesterday’s CDC data is concerning and significantly shifts the landscape. 
Across the country and here in Michigan, we are seeing a rise in cases and are finding the 
delta variant is more contagious. The new CDC data suggests that even vaccinated 
individuals can in some cases spread the virus. 
These recent developments and my commitment to keeping students, staff and faculty safe 
have led me to update our requirements, including those for the fall semester. Today, I am 
announcing two key actions: 
1. All individuals are required to wear masks indoors beginning Aug. 1 in all campus 
buildings and other MSU facilities in East Lansing and throughout the state. This 
requirement will be in place for at least the first weeks of the fall semester. 
2. All students, faculty and staff are required to be fully vaccinated against COVID-19 
with an FDA-authorized or WHO-approved vaccine by Aug. 31. Limited exemptions 
for medical or religious reasons will be provided. 
More details about these new requirements will be shared in the coming days. 
For those who have not received a COVID-19 vaccination yet, it’s time to do so. You can 
receive one through the MSU Health Care Pharmacy or find a vaccination provider near you 
by visiting vaccines.gov. Students, faculty or staff who have not completed their vaccine 
regimen and those exempt from the vaccine for health or religious reasons will be required 
to take part in MSU’s Early Detection Program or other measures that help keep them safe. 
We are all in this battle against COVID-19 and its variants together and I firmly believe the 
actions we are taking today are necessary measures. As we have throughout the pandemic, 
we will continue to monitor the situation and will adjust as needed. I appreciate the 
commitment of our students, faculty, staff and others to protect our Spartan Community. 
Sincerely, 
Samuel L. Stanley Jr., M.D. (he/him) 
President 
 
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EXHIBIT H 
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Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1331   Filed 11/05/21   Page 83 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1332   Filed 11/05/21   Page 84 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1333   Filed 11/05/21   Page 85 of 92

EXHIBIT I 
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Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1335   Filed 11/05/21   Page 87 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1336   Filed 11/05/21   Page 88 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1337   Filed 11/05/21   Page 89 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1338   Filed 11/05/21   Page 90 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1339   Filed 11/05/21   Page 91 of 92

Case 1:21-cv-00756-PLM-SJB   ECF No. 55-1,  PageID.1340   Filed 11/05/21   Page 92 of 92

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