COVID-19 vaccine hesitancy among people with epilepsy: an updated systematic review and meta-analysis

OBJECTIVE: To systematically review and meta-analyze COVID-19 vaccine hesitancy among individuals with epilepsy. METHODS: Following PRISMA 2020 guidelines, we searched Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS, PsycINFO databases, and grey literature through February 6, 2026. We included studies addressing COVID-19 vaccination hesitancy in adults with epilepsy, with no date or language restrictions. Two reviewers independently screened articles, extracted data, and assessed quality using the Newcastle-Ottawa Scale (NOS). Meta-analyses were conducted using random-effects models, with heterogeneity assessed using I² statistics. The certainty of evidence was evaluated using the GRADE criteria. RESULTS: Fourteen studies comprising 4230 participants were included. Overall vaccination willingness was 51.7% (95% CI: 36.6-68.8%, I²=98%). Among unvaccinated individuals, 44.2% (95% CI: 26.6-61.8%, I²=95%) expressed willingness to be vaccinated. Well-controlled epilepsy was associated with higher vaccination rates (OR 1.91, 95% CI: 1.49-2.46, I²=0%). Conversely, frequent seizures (daily/weekly) were associated with lower vaccination likelihood (OR 0.52, 95% CI: 0.35-0.76, I²=0%). The primary reasons for vaccine hesitancy were fear of seizure worsening (23.8-88.5% across studies) and concerns about side effects (13.0-53.0%). Methodological quality was generally poor, with only one study rated as "satisfactory" using NOS criteria. GRADE assessment indicated very low certainty of evidence due to serious risk of bias, inconsistency, and imprecision. CONCLUSIONS: COVID-19 vaccine hesitancy remains present in people with epilepsy, primarily driven by concerns about seizure exacerbation. Individuals with well-controlled epilepsy show higher vaccination acceptance. Healthcare providers should address specific concerns about seizure control while emphasizing vaccine safety data. High-quality prospective studies using validated instruments are recommended.