Final COVID-19 Vaccination Status, Attitude, and Adverse Events Among People With Multiple Sclerosis: A Cross-Sectional Study From Egypt

Even following the US Food and Drug Administration (FDA) approval of the SARS coronavirus 2 (COVID-19) vaccination in 2021,¹  acceptance among global citizens varied.^2-4  According to several studies, more than one-third of the population studied did not receive a COVID-19 vaccination despite the critical situation of the pandemic.^2,3,5,6  Hesitancy about taking the vaccine was more prevalent among people with chronic illnesses, including those with multiple sclerosis (MS).^7,8 

Clear guidance about the necessity and urgency of offering COVID-19 vaccines to people with MS was soon released,^9-12  but some members of the MS community continued to have concerns about it.^8,13  People with MS in Egypt had a high rate of vaccine hesitancy—26% at the peak of the pandemic.¹⁴  In May 2023, the World Health Organization (WHO) declared an end to COVID-19 as a global health emergency,¹⁵  but data about the final vaccination rate in Egypt are scarce. This study aims to uncover the 2023 COVID-19 vaccination status among a cohort of people with MS, their feelings and fears during and then following the pandemic, and any reported adverse events (AEs) from vaccination.

This was a cross-sectional, self-administered survey given to adults with MS seen at the Alexandria University MS Clinic between June 2023 and November 2023. People with relapsing MS (RMS) and progressive MS (PMS) were eligible.

The survey had 6 sections: (1) sociodemographic characteristics; (2) clinical data about the disease (eg, disease duration, phenotype, Patient-Determined Disease Steps [PDDS] score,¹⁶  number of relapses in the past year, and disease-modifying therapies [DMTs]); (3) fear of COVID-19 scale (FCV-19S) score¹⁷ ; (4) questions about prior exposure to COVID-19 and commitment to preventive measures; (5) previous vaccinations, DMTs, steroids, and attitudes toward the vaccine; (6) vaccine-related AEs and postvaccination relapses.

All data were analyzed using the IBM SPSS software package, version 20.0. For comparison based on data type, χ², Monte Carlo, and Fisher exact tests were used.

Ethical approval was obtained from the ethics committee of Alexandria University School of Medicine (IRB no 0012098 [expires October 6, 2025]), which operates according to the International Conference on Harmonization Good Clinical Practice Guideline and applicable local and institutional regulations and guidelines. The ethics committee has a federal-wide assurance from 2010 (FWA no. 00018699 [expires January 21, 2026]).

Of 200 patients invited, 150 (75%) responded to the survey during the study period. The median age of the participants was 35.5 years (range, 19-59). Approximately 77% were women; 47% were highly educated (TABLE S1); 84% had relapsing MS (TABLE S2). The median disease duration was 4 years (range, 0.019-22), and the median PDSS was 2 (range, 0-7). Approximately 54% (n = 81) received a COVID-19 vaccination (TABLE 1, TABLE S3). Sinopharm, Pfizer, and AstraZeneca vaccines were the most common brands given to 39.2%, 24.1%, and 19%, respectively (TABLE 1).

The median FCV-19S score was 11 (range, 7-35). Approximately 42.7% of the patients experienced COVID-19 symptoms, and 14.7% had positive COVID-19 tests. Two participants (1.3%) were hospitalized due to COVID-19 infection. The exposure data and commitment to infection control precautions are detailed in Table S2. Of 150 participants, 66 (44%) received 2 doses of COVID-19 and 69 (46%) did not receive any vaccines (Table S3).

Of those who did not receive the vaccine, 65.2% did not want to receive the vaccine at all. The main 2 causes were worries about making their MS worse (69.3%) and being worried about long-term AEs (63.3%) (Table S3).

Of the 81 people with MS who received the vaccine, 20 (24.7%) had a clinical relapse 1 month before vaccination; 16 (19.8%) received corticosteroids during the month before vaccination; and 3 (3.7%) postponed their DMT because of vaccination. They were on dimethyl fumarate, fingolimod, and rituximab. Of note, the only factor significantly related to vaccination state was FCV-19S scores. Two-thirds (65.2%) of patients with a high level of fear did not receive the vaccine vs 67.6% of those with moderate fear and 46.2% of those with low fear (P = .049).

Fatigue was the most common AE, occurring in 48% of participants in general and in 32% after the second dose (FIGURE 1A). Five (≈ 6.2%) people with MS who received the COVID-19 vaccination had a relapse following vaccination. The relapses were confirmed clinically but not radiologically. The details of those who had a relapse are compared with those who did not have a relapse in TABLE S4. Of note, relapse occurrence was higher for patients receiving immunosuppressants than for those receiving immunomodulatory DMTs. (All DMTs used were considered immunosuppressants except interferons.) Relapse symptoms are depicted in FIGURE 1B. Imbalance was the most common neurological symptom reported (18%). This was followed by weakness (15%), gait problems (15%), visual disturbances (14%), urinary or bowel symptoms (14%), and sensory symptoms (9%) (Figure 1B).

Although the COVID-19 pandemic is no longer a health emergency, it was essential to investigate vaccine hesitancy among the Egyptian people with MS to help develop regulations and educational programs for the future. We found that approximately only half of the Egyptian people with MS surveyed received the COVID-19 vaccine, mainly due to fear of potential AEs or a negative impact on their MS. In this cohort, 5% had an MS relapse, but no other serious AEs were reported.

Compared to the WHO's 70% vaccination target,¹⁸  the vaccination status among Egyptian people with MS is inadequate, especially taking into consideration that 27.3% of those who received the vaccine were forced to do so for work- or travel-related reasons. These numbers are similar to those reported by Ghanem et al,¹⁴  who studied 289 people with MS from Cairo and found a hesitancy rate of 26.3%. However, in their study of 160 Egyptian people with MS, Gad et al¹⁹  reported a vaccination rate of 40.6%. Although the vaccination rate was low among people with MS in Egypt (either in our study or in previous Egyptian studies^14,19 ), the rate is slightly higher than that noted among the general Egyptian population, where about 49% (of 18,107 individuals interviewed) were vaccinated.²⁰  This higher rate among people with MS may be due to better education from their neurologists or their perception that they are more vulnerable than people who do not have MS. Vaccination rates among people with other neurological disorders were similar, including immune-mediated diseases (59.2%)²¹  and other diseases such as cerebrovascular disorders (41.6%),²¹  headache (69.2%),²¹  or epilepsy (39.5%).²²  People with MS in Egypt were more likely to receive a COVID-19 vaccination than those with stroke or epilepsy, but less likely to receive it compared to those with headache. Regardless, the vaccination rate in Egypt, whether among the general population or among patients with various neurological disorders, is low compared to the WHO target.¹⁸ 

The vaccination numbers from Egypt are significantly lower than what has been reported in the literature. For instance, in a 2022 systematic review and meta-analysis of 5983 people with MS mainly from the United States, the United Kingdom, Ireland, Iran, and China, only 2% of people with MS were unwilling to receive COVID-19 vaccines.²³  In a study of 4955 people with MS from the North American Research Committee on Multiple Sclerosis (NARCOMS), 84.1% received a COVID-19 vaccine.²⁴  Similarly, of 193 people with MS in Germany, 84.5% and 78.2% received first and second COVID-19 vaccine doses, respectively.²⁵  Data from 2 Australian health care services in 2021 showed a vaccination rate of 82.9% among 281 people with MS.²⁶  The differences noted are likely due to fear and poor knowledge about the vaccine safety, efficacy, and potential AEs.

The case is different in other countries in the Middle East and North Africa (MENA) region. A cross-sectional study of 3041 people with MS from MENA reported a 60.2% willingness rate to receive a COVID-19 vaccine booster.²⁷  Alroughani et al, in a study from Kuwait of 647 people with MS, reported a 59.28% vaccination rate.²⁸  Felemban et al reported that 89.02% of 173 people with MS in Saudi Arabia received the vaccine.²⁹  The only region where the vaccination rate was lower than our study was South Africa, with 17.5% of 394 people with MS receiving the COVID-19 vaccine.³⁰  Although the rate was low, approximately 60.2% had a positive attitude toward vaccination. Here again it seems that the Egyptian population might need specific education as well as detailed studies to investigate what is engendering such a negative attitude toward vaccination.

Fear of vaccination was similar in our study to what has been reported in the literature. In the NARCOMS cohort, the reasons for not getting the COVID-19 vaccine were fear of potential AEs (47.7%), possible lack of efficacy (13.7%), and uncertainty about need for the vaccine (17.1%).²⁴  And, unlike with our cohort, many factors were significantly correlated to receiving the vaccine, including older age, higher socioeconomic status, physical activity level, and DMT.²⁴  Similarly, age, level of education, Expanded Disability Status Scale score, disease duration, depression, psychological status, and DMT use affected reception of COVID-19 vaccination.²⁵  In a German study, concern about potential AEs was the most common reason to not get the vaccine (82.1%) followed by believing the vaccine was not adequately tested (64.3%).²⁵  In an Australian study in 2021, young age and short disease duration (ie, 5 years or less) were the main factors determining the vaccination status.²⁶  In Saudi Arabia, the main determinant for getting the COVID-19 vaccine was education level (P = .004).²⁹  In a Malawi study, the lack of knowledge about COVID-19 vaccination benefits and importance was the main factor in people choosing to not get the vaccine.³⁰ 

Vaccine AEs in our cohort were mild, with fatigue being the most commonly reported symptom by approximately half of the sample. The relapse rate following vaccination was 6.2%. Patients who had a relapse following vaccination were similar to those who did not experience a relapse except that they were on immunosuppressants. This might be attributed to the vulnerability of the host immune system increasing the risk of vaccine-induced inflammatory response and promoting a relapse. In an Egyptian cohort, the relapse rate following vaccination was 7.7%, and the prevalence of vaccine-related AEs was 33%, mainly in the form of injection-related reactions and general constitutional symptoms.¹⁹  In Western countries, the prevalence of AEs related to COVID-19 was 52.8%²⁵  and the relapse rate was 6.7%.²⁵  In the Kuwait cohort, 1.31% had relapses following vaccination.²⁸ 

Taken together, it is clear that the COVID-19 vaccination rate among people in Egypt with MS is poor. This is similar to the population in Egypt in general, but inadequate compared with international standards. Although the reported reason for poor vaccination is worry about the potential negative impact of the vaccine on their MS and their general health, in this study, the vaccine did not have any major negative impact on the MS disease or the general condition of the Egyptian cohort. Local educational programs about the importance and safety of vaccination should be provided for this vulnerable population. Further studies are also needed to investigate other potential causes of fear of vaccination among this population.

The main strength of this study is that it concerns people with MS in Egypt, a country with a large population but limited publications on this topic, and it is the first (to the best of our knowledge) to assess final vaccination status. The main limitation of the study is that it was performed after the peak of the COVID-19 pandemic. Still, the study's aim was to present the final vaccination state of a vulnerable group of the population and to demonstrate how excessive concerns over vaccine risks affect COVID-19 vaccine uptake.

More than half of the study cohort of people in Egypt with MS did not receive a COVID-19 vaccine mainly due to fear about its potential negative consequences on their MS disease progression; however, all vaccine-related AEs were mild. These findings emphasize the importance of implementing awareness and education programs for patients with chronic diseases in future pandemics.