- GBS patients & Vaccination -

This is what Prof. Thomas Hughes, London, has to say on the issue of GBS-patients and vaccination. (The numbers in parenthesis refer to list of references at the bottom of the page, for further reading):

"What should patients who have had Guillain-Barré syndrome be advised, about future immunisation?"

Guillain-Barré syndrome is thought to be an autoimmune disease. Vaccines stimulate the immune system. Theoretically, stimulating the immune system might exacerbate or lead to a reappearance of an autoimmune disease.

There are anecdotal reports of GBS occurring soon after immunizations (1-5). There was an increase in incidence of GBS after the "swine flu" virus vaccine program in the US in 1976 (6). More recent information suggests that the occurrence of GBS after currently used influenza and other vaccines is extremely rare (7). Case control studies have shown no evidence of a significant increase in risk of having received an immunization preceding GBS, compared with contemporary controls (8;9;10). Retrospective examination of the incidence of GBS for the seasons of the 1992-3 and 1993-4 influenza vaccination programs in the US suggested that influenza vaccination only caused 1-2 extra cases of GBS per million vaccinees (11).

Despite this evidence, the belief that GBS is an autoimmune condition and the knowledge that immunizations are designed to activate the immune system give rise to continued unease about immunization following the disease (12;13).
This unease is enhanced by a report of two cases of GBS recurring following swine influenza vaccine (14). In addition recurrent attacks of CIDP have followed tetanus toxoid immunization (12;15).
However many patients have received immunizations after the acute phase of their disease, sometimes repeatedly (16), without suffering a relapse. The number of such patients has, however, not been monitored and the actual risk is not known. In the absence of adequate evidence and the difficulty of conducting an adequately powered randomised trial, it would be appropriate to audit a recovered GBS patient population to discover what proportion has received immunisations and what was the outcome.

Although the experiment has never been done in GBS, patients with multiple sclerosis have been randomized to receive or not receive influenza vaccine and no evidence emerged to suggest that immunisation stimulated relapse (17;18). In a recent thorough review Flachenecker et al. (19) found no evidence that immunisation adversely effects the course of multiple sclerosis. In the case of influenza vaccine and hepatitis B vaccines this conclusion was based on large epidemiological studies.

Conclusion

  1. In patients who have previously had GBS, recurrence of GBS after immunisation is rare.
  2. The need for a particular immunisation requires careful evaluation on an individual basis.
  3. Immunisations should not be performed during the acute phase of GBS and should probably be avoided until at least 1 year after the onset of the disease.
  4. If GBS occurred within 6 weeks after an immunisation, the patient should not receive that immunisation again.

The above advice has been approved by the Medical Advisory board of the GBS Support Group UK.

References

  1. Bakshi R, Graves MC.
    Guillain-Barre syndrome after combined tetanus-diphtheria toxoid vaccination.
    J Neurol Sci 1997;147:201-2.
  2. Gervaix A, Caflisch M, Suter S, Haenggeli CA.
    Guillain-Barré syndrome following immunisation with Haemophilus influenzae type b conjugate vaccine.
    Eur J Paed 1993;152:613-4.
  3. Gross TP, Hayes SW.
    Haemophilus conjugate vaccine and Guillain-Barré syndrome.
    Journal of Pediatrics 1991;118:161.
  4. Holliday P, Bauer RB.
    Polyradiculoneuritis secondary to immunisation with tetanus and diphtheria toxoids.
    Arch Neurol 1983;40:56-7.
  5. Morris K, Rylance G.
    Guillain-Barré syndrome after measles, mumps, and rubella vaccine.
    Lancet 1994;343:60.
  6. Schonberger LB, Bregman DJ, Sullivan-Bolynai JZ, Keenlyside RA, Ziegler DW, Retailliau HR, Eddins DL, Bryan JA. Guillain-Barre syndrome following vaccination in the National Influenza Immunization program, United States 1976-1977.
    Am J Epidemiol 1979;110:105-23.
  7. Fenichel GM. Assessment: Neurologic risk of immunization: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
    Neurology 1999; 52:1546-52.
  8. Winer JB, Hughes RAC, Anderson MJ, Jones DM, Kangro H, Watkins RFP.
    A prospective study of acute idiopathic neuropathy. II. Antecedent events.
    J Neurol Neurosurg Psychiatry 1988;51:613-8.
  9. Rees J, Hughes R.
    Guillain-Barré syndrome after measles, mumps and rubella vaccine.
    Lancet 1994;343:733.
  10. Hughes RAC, Rees J, Smeeton N, Winer J.
    Vaccines and Guillain-Barré syndrome.
    Brit Med J 1996;312:1475-6.
  11. Lasky T, Terracciano GJ, Magder L, Koski CL, Ballesteros M, Nash D, Clark S, Haber P, Stolley PD, Schonberger LB, Chen RT. The Guillain-Barré syndrome and the 1992-1993 and 1993-1994 influenza vaccines.
    New Engl J Med 1998;339:1797-802.
  12. Hughes RAC, Choudhary PP, Osborn M, Rees JH, Sanders EACM.
    Immunisation and risk of relapse of Guillain-Barré syndrome or chronic inflammatory demyelinating polyradiculoneuropathy.
    Muscle Nerve 1996;19:1230-1.
  13. Ropper AH, Victor M.
    Influenza vaccination and the Guillain-Barré syndrome.
    New Engl J Med 1998;339:1845-6.
  14. Seyal M, Ziegler DK, Couch JR.
    Recurrent Guillain-Barre syndrome following influenza vaccine.
    Neurology 1978;28:725-6.
  15. Pollard JD, Selby G.
    Relapsing neuropathy due to tetanus toxoid.
    J Neurol Sci 1978;37:113-25.
  16. Wijdicks EFM, Fletcher DD, Lawn DD.
    Influenza vaccine and the risk of relapse of Guillain-Barré syndrome.
    Neurology 2000;55:452-3.
  17. Myers LW, Ellison GW, Lucia M, Novom S.
    Swine-influenza vaccination in multiple sclerosis.
    New Eng J Med 1976;295:1204.
  18. Miller AE, Morgante LA, Buchwald LY, Coyle PK, Krupp LB, Doscher CA, Lublin FD, Knobler RL, Trantas F, Kelley L, Smith CR, La Rocca N, Lopez S.
    A multicenter, randomized, double-blind, placebo-controlled trial of influenza immunization in multiple sclerosis.
    Neurology 1997;48:312-4.
  19. Flachenecker P, Moriabadi N, Niewiesk S, Rieckmann P.
    Immunization and multiple sclerosis: clinical and immunological implications.
    The International MS Journal 2001;7:79-87.

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