A PracticeUpdate interview with Prof Michael D. Kornberg MD, PhD, Assistant Professor of Neurology, Division of Neuroimmunology and Neurological Infections; Associate Director, Adult Neurology Residency Program, Immunology and Cellular and Molecular Medicine Graduate Programs, Johns Hopkins University, Baltimore, Maryland
PracticeUpdate: The most significant topic presently is about the safety of COVID-19 vaccines. Are there possible risks associated with the vaccination?
Dr. Kornberg: At this point, there are no special concerns in people with underlying or preexisting neurological disorders. There have been a few neurological complications of the available vaccines that have been reported. Those do not seem to be of any higher risk in people with preexisting neurologic disease. In particular, there are very low risks of cerebral venous sinus thrombosis associated with the adenovirus vaccines. In this country, that’s the Johnson & Johnson vaccine. That’s about 1 in 150,000 people, so it’s extremely low. Again, not more common in people with underlying neurologic disease. There have been some reports of an increased risk of Guillain-Barre, also with the adenovirus vaccine. The most recent estimate is that may be 4 people in about 100,000. So again, very low. There’s no evidence that having prior Guillain-Barre or having CIDP (chronic inflammatory demyelinating polyneuropathy) increases that risk.
PracticeUpdate: Are there special concerns related in case of patients with neurological disorders?
Dr. Kornberg: A big concern for my patients, and among providers who take care of people with MS or other autoimmune conditions, is a concern that you might precipitate a relapse because you’re revving up the immune system. The concern is you can precipitate an autoimmune attack. So far, that has not been seen with any of the COVID-19 vaccines. There’s a recent study that looked at more than 300 patients with MS and found no difference in relapse rate in the two months prior and the two months after vaccination. We have a lot of evidence from prior vaccines, particularly the influenza vaccine, that has suggested over many years that there really aren’t any vaccines that have been associated with an increased risk of MS relapse. The bottom line is that we believe that these vaccines are very safe for people with underlying neurologic conditions.
PracticeUpdate: Have there been any incidents of exaggeration of existing risks in your clinical practice with patients having neurological disorders like MS?
Dr. Kornberg: The short answer is no. There has been a lot of concern among physicians and patients alike about the risk of precipitating a relapse with vaccination. That has not been the case with vaccines in general, and we have not seen that with the COVID-19 vaccines in particular. In the vast majority of cases, I do not have concern for people with MS in terms of exacerbating their underlying condition.
The one qualification to that is that with many neurologic conditions, and MS is one of them, any time there is a stressor to the body, [for example] if someone develops a fever or a viral illness, or a urinary tract infection, it’s very common for their neurologic symptoms to transiently worsen. I have seen [this happen in] people who have received the COVID-19 vaccines, particularly after the second dose of the mRNA vaccine, when a lot of people feel crummy. They develop a fever, chills for 24 hours. In that context, their neurologic deficits will often worsen. But it is transient. In the same way that those systemic symptoms, the fever, the myalgias, last for 24 to 48 hours and then resolve, the worsening of neurologic symptoms follows a similar course. By a week, people are back to themselves. That’s the only caveat.
PracticeUpdate: Your literature review summarizes data and information regarding risks of COVID-19 as well as benefits of vaccination in adult patients with neurological disorders. Could you summarize them?
Dr. Kornberg: The bottom line is, just as for the general population, the benefits of vaccination far exceed the risks, essentially no matter who you are. When it comes to risks of COVID-19, in people with underlying neurologic conditions, the impact of those conditions on risk is really a factor of disability. In MS, for instance, we know that people who have ambulatory dysfunction, people who have more severe disability based on our traditional disability scales, are at higher risk of severe complications from COVID-19. That’s really a measure of frailty, in the same way that aging and other comorbidities can contribute to severe disease. Similar findings have been seen in people with other neurologic conditions, particularly if there’s respiratory compromise or bulbar symptoms, just as risk factors for respiratory disease and frailty.
Having a neurologic condition by itself, if you take out the frailty and disability part of it, does not impart an increased risk from COVID-19. For the vast majority of my MS patients who don’t have substantial disability, their MS does not impact their potential recovery from COVID-19, compared to the general population.
In terms of the vaccines, as I’ve already discussed, the bottom line is that they are extremely safe. There are not any complications of these vaccines that have been shown to be more common in people with neurologic conditions. That includes MS. The complications that have been identified in the general population, fortunately, are extremely low risk. No matter who you are, your risks from having COVID-19 are going to be much, much higher than the risks associated with vaccination.