Is the COVID (Coronavirus Disease 2019) vaccine associated with any neuromuscular diseases, such as Guillain-Barré Syndrome (GBS)?

COVID-19 Vaccine Association with Neuromuscular Diseases

The COVID-19 vaccine has been associated with a small risk of neuromuscular diseases, particularly Guillain-Barré syndrome (GBS), with the strongest association seen with adenoviral vector vaccines rather than mRNA vaccines. While the risk exists, it is rare and the benefits of COVID-19 vaccination in preventing severe COVID-19 illness and death outweigh the potential risks of these rare adverse events for most individuals.

Guillain-Barré Syndrome (GBS) and COVID-19 Vaccines

Evidence of Association

• The Advisory Committee on Immunization Practices (ACIP) identified a statistical signal for Guillain-Barré syndrome (GBS) among persons aged ≥65 years receiving mRNA COVID-19 vaccines during the 2023-2024 season 1.
• This signal was new, as an association between GBS and mRNA COVID-19 vaccines had not been identified before the 2023-2024 season 1.
• A UK population-based study found that first-dose ChAdOx1 nCoV-19 (AstraZeneca) vaccination was associated with an excess GBS risk of 0.576 cases per 100,000 doses (95% CI 0.481-0.691) 2.
• No excess risk was observed with tozinameran (Pfizer) or second doses of any COVID-19 vaccine 2.

Clinical Characteristics of Vaccine-Associated GBS

• A systematic review of 258 neuromuscular disease cases following COVID-19 vaccination found that 171 cases were GBS 3.
• GBS cases were predominantly male (63%) 3.
• The median time from vaccination to symptom onset was less than 2 weeks 3.
• Symptoms mainly appeared following the first dose of vector vaccines, with no specific pattern for mRNA-based vaccines 3.
• No specific clinical features, including facial weakness, distinguish vaccination-related GBS from non-vaccinated cases 2.

Other Neuromuscular Diseases Associated with COVID-19 Vaccines

A systematic review identified additional neuromuscular conditions associated with COVID-19 vaccination 3:

• Parsonage-Turner syndrome (40 cases)
• Myasthenia Gravis (22 cases)
• Facial nerve palsy (19 cases)
• Single fiber neuropathy (5 cases)
• Tolosa-Hunt syndrome (1 case)

Risk Assessment and Recommendations

Risk Factors

• Age appears to be a factor, with the GBS signal identified specifically in those aged ≥65 years 1.
• Pre-existing neurological conditions may require special consideration:
  • Multiple sclerosis (MS) patients can receive COVID-19 vaccines, but timing should be coordinated with disease-modifying therapies 1.
  • Patients receiving immune reconstitution therapies (IRT) should be vaccinated 6 months after treatment 1.

Benefit-Risk Assessment

• The ACIP emphasizes that any real or theoretical risk of vaccine adverse events must be considered in the context of benefits in preventing COVID-19 and its potentially serious complications 1.
• The 2024-2025 COVID-19 vaccines are recommended for all persons aged ≥6 months to target currently circulating SARS-CoV-2 strains and provide protection against severe COVID-19–associated illness and death 1.

Clinical Management Considerations

For Patients with History of GBS

• There is evidence of recurrent GBS triggered by COVID-19 infection in patients with a history of GBS 4.
• Patients with a history of GBS should be monitored closely if they develop COVID-19 infection.

For Patients with Neurological Disorders

• Vaccination is recommended for patients with multiple sclerosis (MS) 1.
• For MS patients on disease-modifying therapies:
  • Those receiving ocrelizumab should be vaccinated 4–6 weeks before starting treatment or 4–6 months after ending treatment 1.
  • Patients on immune reconstitution therapies (alemtuzumab, rituximab, ocrelizumab) should be vaccinated 6 months after treatment 1.
  • For those on high-dose or long-term corticosteroids, vaccination is recommended 4–6 weeks after cessation of treatment 1.

Monitoring and Reporting

Healthcare providers should:

• Be vigilant for symptoms of GBS (progressive weakness, numbness, paresthesia, areflexia) in recently vaccinated individuals.
• Report suspected cases of vaccine-associated adverse events to appropriate surveillance systems.
• Consider early intervention with intravenous immunoglobulin (IVIG) or plasmapheresis for suspected GBS cases 5, 6.

Conclusion

While there is evidence of a rare association between COVID-19 vaccines (particularly adenoviral vector vaccines) and neuromuscular diseases like GBS, the overall risk is very low. The benefits of COVID-19 vaccination in preventing severe disease and death continue to outweigh these rare risks for the general population.