Other studies have reported a small number of people who have had VZV reactivations following vaccination, including a set of 10 patients with rheumatic diseases in Taiwan.
But case reports are not proof of anything.
“It’s purely speculative when you look at a single case report and try to conclude causation or even an association,” Dr. Maria Nagel, a neurologist and neurovirologist who studies VZV at the University of Colorado School of Medicine, told us. Saying there’s a link would be “like a few people reporting that they stubbed their toe after vaccination and we conclude that [the] vaccine causes stubbed toes.”
“The fact that somebody’s gotten the vaccine and then gotten Ramsay Hunt, what you’d have to do is demonstrate not only a temporal relationship, but the fact that it occurs at a higher rate in that population than in the population in general,” Berger said. “You can’t use anecdote as data.”
The results from larger epidemiological studies about COVID-19 vaccination and shingles or VZV reactivations have been mixed. A few, including an analysis of data from a health care organization in Israel, have identified an association, but others have not.
Data from safety monitoring systems in the U.S. do not suggest a connection.
“CDC has detected no unusual or unexpected patterns of Ramsay Hunt syndrome following immunization that would indicate COVID-19 vaccines are causing or contributing to this condition,” a Centers for Disease Control and Prevention spokesperson told us in an email. “Evidence at this time does not support a causal association between COVID-19 vaccination and the development of Ramsay Hunt syndrome or herpes zoster (shingles). Safety monitoring for these outcomes is ongoing.”
“The evidence is pretty thin,” Berger said, adding that he was “skeptical” of a “meaningful association” between vaccination and Ramsay Hunt.
The available evidence also does not support a connection between COVID-19 vaccination and Bell’s palsy, a more common and less severe form of facial paralysis than Ramsey Hunt that is sometimes thought to be due to VZV reactivation, although more often is thought to be due to reactivation of herpes simplex virus. In the vaccine trials for the two COVID-19 mRNA vaccines, there were a few more people who developed Bell’s palsy in the vaccinated versus the placebo groups, but the frequency was similar to what would be expected in the general population. Subsequent monitoring has not revealed safety concerns.
Given that large-scale studies are inconclusive about a possible link between COVID-19 vaccination and VZV reactivation and the lack of such a safety signal in the U.S., the claim that there is a link or that the vaccine is responsible for Bieber’s condition is unsupported.
Even if vaccination does increase a person’s risk of VZV reactivation, the risk would likely be low, and would not mean the risks of the vaccine would outweigh the benefits, contrary to posts that attempt to use Bieber’s case to argue against vaccination. Indeed, even many of the published papers that propose a possible link to Ramsay Hunt or shingles are careful to note this.
Ramsay Hunt Syndrome Triggers
It’s not fully understood what causes VZV reactivations, such as with shingles and Ramsay Hunt syndrome, but is thought to primarily be the result of the immune system’s inability control the virus.
Older people and those with weakened immune systems are at higher risk, and medications, infections and stress are possible triggers.
But sometimes there is no obvious cause.
“We also see it in individuals that are otherwise perfectly healthy, immunologically, who are young,” Berger said of shingles. “It just is one of those things that can occur without there being a known precipitant or a good explanation.”
Nagel said that if she saw a younger patient, such as 28-year-old Bieber, with Ramsay Hunt, she would first ask when he had chickenpox as a child.
“If you’re four years old or under, you don’t have good immune memory. And those kids tend to flare up virus at a younger age,” she said. “They might get shingles, also known as herpes zoster, when they’re 12 years old, or in their 20s.”
She said she’d also ask about recent infections and other medical conditions or medications that weaken the immune system.
Bieber, notably, had a mild case of COVID-19 in mid-February.
Multiple case reports have suggested that COVID-19 increases the risk of VZV reactivation, but as with the case reports of events following vaccination, these reports do not mean anything on their own. One large study found that among adults 50 years of age and older, those who had had COVID-19 were 15% more likely to develop shingles than those who had not been sick with the coronavirus. But another large study — the Israeli one that found an association between the Pfizer/BioNTech vaccine and shingles — did not observe an increased risk of shingles with COVID-19.
Berger, who said he usually sees a couple of cases of Ramsay Hunt a year, said he has not seen an uptick in cases during the pandemic or with the rollout of vaccines.
Regardless of the cause, if someone is experiencing facial paralysis or other symptoms of Ramsay Hunt, Berger and Nagel both said to seek medical attention as soon as possible.
“The longer you wait, the more likely there is to be permanent damage to the nerve,” Berger said. Ramsay Hunt is typically treated with antiviral medications and steroids to reduce swelling, he said, and about half of patients fully recover, but it can take months.
Ramsay Hunt Syndrome Prevention
There are chickenpox and shingles vaccines that can reduce the risk of VZV infection or reactivation, and thereby lower the risk of Ramsay Hunt syndrome.
The chickenpox vaccine is a two-dose vaccine made from weakened, or attenuated, varicella-zoster virus, which is around 90% effective in preventing the disease. While some people who are vaccinated get shingles later, the CDC says this is “much less common after vaccination than after chickenpox disease.”
The chickenpox vaccine was first used in the U.S. in 1995 as a single-dose vaccine. Bieber, who is Canadian, likely was never vaccinated, as the vaccine wasn’t licensed there until 1998 and was not part of routine childhood immunization programs until 2000 or later, when he was 6.
Older people 50 and above and immunocompromised adults 19 years of age and older are eligible to receive the shingles vaccine, which prevents shingles and long-term nerve pain due to shingles called postherpetic neuralgia. The vaccine, known by its brand name Shingrix, is a two-dose vaccine that does not contain live virus and is 85% effective or more, depending on age, in healthy people.
Baseless Claim About Hailey Bieber
In addition to Justin’s Ramsay Hunt syndrome, social media posts have — without evidence — blamed Hailey Bieber’s transient ischemic attack, or TIA, on COVID-19 vaccination.
As we have written, only one of the FDA-authorized vaccines, the Johnson & Johnson vaccine, has been linked to blood clots, but it is a very particular and rare problem known as thrombosis with thrombocytopenia syndrome, or TTS. In the condition, which has occurred in about 4 cases per million doses of vaccine administered, blood clotting occurs together with low levels of platelets.
Hailey’s description of her clinical case, however, bears no suggestion that she suffered from TTS, nor is there evidence that she was even vaccinated with the Johnson & Johnson vaccine.
In an April 27 YouTube video, Hailey described her experience in detail, never mentioning COVID-19 vaccination — and in fact giving other reasons why doctors suspect she had a blood clot in her brain.
According to her account, her doctors attributed the clot to a “perfect storm” of three factors.
“One was that I had just recently started birth control pills, which I should have never been on because I am somebody who suffered from migraines anyway, and I just did not talk to my doctor about this,” she said.
“The second thing was I had recently had COVID, and that was something that they thought was a contributing factor,” she continued. “And the third thing was that I had recently gone on a really long flight — I had flown to Paris and back in a very short amount of time — and I slept through the whole flight both ways, didn’t get up and move around, never thought about wearing compression socks.”
Hailey’s doctors also discovered she had a natural opening between the two chambers of her heart called a patent foramen ovale, which she had been born with and had likely allowed the clot to travel to her brain and cause the TIA. She has since had surgery to close the hole.
It’s unclear when she had COVID-19, but numerous studies have now shown there is an increased risk of clotting and cardiovascular problems after infection with the coronavirus.
Dr. Adam Cuker, a hematologist with expertise in blood clots at Penn Medicine, told us that her case did not raise any concerns about the vaccines.
“It sounds like she developed a DVT and then a piece broke off, traveled through the hole in her heart … and into her brain,” he said, referring to the deep vein thrombosis, the technical term for a blood clot. “This process is called paradoxical embolism.”
If she did have TTS as a result of the J&J vaccine, Cuker said, her platelets would have been low — something that he thought was highly likely to have been checked — and anti-platelet factor 4 antibodies would also be elevated. Bieber mentions neither, but does say in her video that while at the hospital her doctors ran a lot of tests, including “blood tests to see if I had a clotting disorder.”
“Much more likely, she developed a garden variety DVT with the risk factors of hormonal contraception, long-haul travel, and possibly recent COVID,” he said. “There is nothing here that suggests a link with this event and vaccination.”
Editor’s note: SciCheck’s COVID-19/Vaccination Project is made possible by a grant from the Robert Wood Johnson Foundation. The foundation has no control over FactCheck.org’s editorial decisions, and the views expressed in our articles do not necessarily reflect the views of the foundation. The goal of the project is to increase exposure to accurate information about COVID-19 and vaccines, while decreasing the impact of misinformation.
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