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Even if your instances are behind ALBs or ELBs they may not be protected if they make outbound connections to the internet.

Is this so? Can this kernel panic also be triggered in TCP connections initiated by the victim? I can't find a conclusive mention of this anywhere.

As each direction of a TCP connection has its own MSS, it would make sense that an attacker's server could exploit this.

This is so. Both passive and active connections are at risk.