Are Vaccines Safe after Guillain-Barré and Chronic Inflammatory Demyelinating Neuropathy?

Abstract & Commentary

By Michael Rubin, MD, Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Rubin reports no financial relationships relevant to this field of study.

Synopsis: Vaccines appear to be safe for patients who have been previously diagnosed with GBS or CIDP, and are recommended in appropriate individuals.

Source: Kuitwaard K, et al. Recurrences, vaccinations and long-term symptoms in GBS and CIDP. J Peripher Nerv Syst 2009; 14:310-315.

Is it safe to vaccinate a patient with a prior history of guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyneuropathy (CIDP)? What is the likelihood of recurrence of GBS even in the absence of vaccination, and what are the long-term consequences of inflammatory demyelinating polyneuropathy? To address these questions, all members of the Dutch Society of Neuromuscular Disorders were sent a set of questionnaires in June 2008, followed by two reminder letters to improve response rates, asking them to reply if they had a diagnosis of GBS, Miller Fisher syndrome, or CIDP. Issues addressed by the questionnaires encompassed prior vaccinations, family history of GBS or CIDP, presence of other autoimmune diseases, and persistent symptomatology. Also included were the short-form (SF-36) health survey, and standardized sub-questionnaires related to pain, fatigue, anxiety, and depression. Statistical analysis comprised the chi-square test, Fisher exact test, Mann-Whitney U test or t-test, and Spearman's correlation coefficient (rs), with a p < 0.05 considered significant.

Of 461 members who received the mailings, 323 responded, two of whom were excluded due to incorrect or lack of diagnosis. Of the remaining 321 patients, 76 had CIDP, and 245 had GBS, four of whom had Miller Fisher syndrome, five had an overlap of Miller Fisher syndrome and GBS, and one had Bickerstaff's encephalitis. Recurrent GBS was reported in 19 patients but could only be confirmed in nine (4%). Immune-mediated polyneuropathy was reported in a family member in eight GBS patients, six of whom had GBS, and one each had CIDP or multifocal motor neuropathy. A single CIDP patient had a grandson with CIDP. Autoimmune disease, usually thyroid, was reported in 23 (9%) and four (5%) patients with GBS and CIDP, respectively. Prior vaccination, usually for the flu, was reported in 23 GBS (9%) and eight (11%) CIDP patients within eight weeks prior to disease onset, but none of 106 GBS patients who were vaccinated (range 1–37 times, total 775 vaccinations) subsequent to their GBS experienced a recurrence. Among 24 CIDP patients who received vaccines (range 1–17 times) following their CIDP, five reported increased symptomatology. Long after diagnosis, pain was reported in 71% and 72% of GBS and CIDP patients, respectively, and it was felt to be severe in 8% and 17 %, respectively. Even years following diagnosis, fatigue was reported in 45% and 25% of GBS and CIDP patients, respectively. Although patients with prior GBS or CIDP continue to experience pain and fatigue long after diagnosis, seasonal vaccination of these patients, particularly GBS, appears to carry a low risk of recurrence.

Commentary

Review of the peer-reviewed literature between 1950 and 2008 supports the notion that vaccinations are only rarely associated with subsequent development of Guillain-Barré syndrome (Haber P, et al. Drug Safety 2009;32;309-323). With the exception of the swine flu vaccine used in 1976–1977, which carries the strongest causal association, such influenza vaccine associations as have been reported appear to be temporal, rather than causal. Current formulations of rabies vaccine, derived from chick embryo cells, are similarly not associated with a greater than expected rate of GBS. No correlation has been confirmed between GBS and oral polio vaccine or tetanus toxoid-containing vaccines, and reported associations of GBS following quadrivalent conjugated meningococcal vaccine (MCV4) lack controlled epidemiological studies and remain inconclusive. From all available data, it appears that the benefits of vaccination outweigh the risks.