By Charles Shepherd, MD,
ME Association, United Kingdom 2001
http://www.cfids.org/archives/2001rr/2001-rr1-article03.asp
There is widespread agreement that a variety of infections
are capable of precipitating chronic fatigue syndrome (CFS) in susceptible individuals. In
l988, Lloyd et al reported that several of their patients had linked the onset of CFS to
receiving a vaccination in the absence of any coincidental infection.l Since
then, other anecdotal reports have also linked vaccinations to the onset of CFS.2,3
The explanation for vaccine-induced CFS may be because the primary purpose of any
vaccine is to mimic the effects of infection on the immune system. If an antigenic
challenge by infection can precipitate CFS, then it is conceivable that vaccines could act
in a very similar manner.
This reasoning is further strengthened by the fact that immunologically
based illnesses, such as arthritis, can occur when a susceptible host and an
environmental trigger, such as an infection or vaccination, interact.
Causal vaccines
My research interest in this aspect of developing CFS is largely based on clinical
evidence from patients seen in my practice over the past 10 years. As a result, I have
gathered details on more than 200 patients with a history of either developing CFS or
experiencing a significant relapse/exacerbation of CFS symptoms following a vaccination.
In addition, I have more than 150 reports referring to such a link from members of myalgic
enceph-alomyelitis (ME) or CFS self-help support groups and/or their physicians throughout
the world.
This data (although unpublished) suggests that tetanus, typhoid, influenza, and hepatitis
B are the most commonly implicated vaccines in cases of CFS. I have reports of very few
cases involving hepatitis A (using immunoglobulin), polio, or rubella vaccine, or those
predominantly given during childhood—-with the possible exception of Bacillus
Calmette--Guerin vaccine (three cases).
Almost all of my cases involve adults, and in a significant minority the vaccine was
administered when the person had not yet fully recovered from an infective illness such as
infectious mononucleosis (known as glandular fever in the U.K.) or had already experienced
an adverse reaction to a previous dose of the same vaccine (as is sometimes the case with
hepatitis B accine).
About one third of my cases involve vaccine-induced/exacerbated CFS following receiving
the hepatitis B vaccine (HBV). Most of these patients are health care workers,
particularly nurses. Most of the other patients received HBV for occupational health
purposes, often as a condition of employment and without any information on side effects,
such as severe neurological reactions.
The prognosis in this group has been poor, with less than 10% of the patients I have
personally followed reporting any significant relief of CFS symptoms.
Although chronic debilitating fatigue is the most frequently reported symp-tom of CFS
after vaccine administration in this group, around 20% also complained of significant
joint pain/arthralgia, a finding consistent with several reports linking HBV to arthritis
and other autoimmune disorders.5
Less than 5% of the patients also reported neurological complications/side effects such as
tremors or one-sided weakness, which appear to be separate from their CFS symptoms.
For instance, one female patient developed an acute disseminated inflammation of the brain
and spinal cord (encephalo-myelitis) shortly after the second dose of vaccine. This was
followed by the gradual onset of CFS.
Hepatitis vaccines are highly immunogenic compounds, and a number of possible explanations
exist as to why they may be more likely to trigger CFS.
One explanation involves a preexisting genetic susceptibility, which after antigenic
stimulation with HBV, results in a pathological process (possibly involving immune complex
formation) leading to a clinical disease.
Another explanation is that a hypersensitivity reaction occurs to a component of HBV, such
as the preservative thimerosal.6
Researchers in Canada, who made similar observations of a link between HBV and CFS,
hypothesized that this may involve an autoimmune reaction with a microscopic form of
demyelination not visible on magnetic resonance imaging.7
Despite growing anecdotal evidence from other experienced physicians who also believe that
HBV can precipitate CFS,2 vaccine manufacturers do not acknowledge any causal
link. In fact, a report by an independent working group in Canada that dismissed any such
causal link is frequently quoted as a reason for dismissing these claims, even though it
contained some very questionable assumptions to support the conclusions.8
For example, the report inaccurately states that chronic carriers of hepatitis B infection
without signs of ongoing liver damage do not complain of tiredness. The report also uses
results from a one-week follow-up study of 700 health care students, which found excessive
short-term tiredness in about 14% after vaccination with HBV to refute any link with
chronic fatigue.
Practical advice
Health care providers caring for CFS patients who require vaccinations clearly must weigh
the pros (i.e., how effective? how necessary?) and cons (i.e., risks of adverse effects
and exacerbation of CFS symptoms) for each individual vaccine. I would advise against
having routine nonessential vaccinations if a patient is:
In the very early stages of CFS, particularly when it obviously follows an infective episode;
Continuing to experience flulike symptoms, including sore throat, enlarged glands, fevers, and joint pains; or
Has previously experienced an adverse reaction to that particular vaccine.
If the vaccination is potentially lifesaving, then
considerations relating to CFS must take a lower priority. As for some of the more
commonly required vaccines, my advice on their use is as follows:
Hepatitis A. Short-lived protection using immuno-globulin does not seem to cause
any problems in CFS patients. I have not received any adverse feedback from CFS patients
who have used hepatitis A vaccine.
Hepatitis B. If a patient requires HBV for occupational health purposes,
clinicians should weigh the pros and cons as previously discussed and then discuss with
the patient.
Influenza. If a patient has any medical condition that could be severely affected
by an attack of the flu, such as heart disease, asthma, or bronchitis, influenza vaccine
should certainly be considered.
My own data indicates approximately 60% of CFS patients experience some form of
exacerbation in their fatigue and flulike symptoms (sometimes quite marked)
following an influenza vaccine.
Meningitis C. My feedback from approximately 30 children and adolescents with CFS
who have been given the meningitis C vaccine in the U.K. is that there were no serious
side effects or exacerbations of CFS symptoms. The only adverse effects reported have been
minor exacerbations of fatigue and headache.
Polio and diphtheria. One research study showed evidence that people with CFS do
not experience adverse reactions to polio vaccination.9 This is also my own
impression from feedback received from patients I have advised receive polio boosters in
relation to foreign travel.
Polio vaccinations or boosters should clearly be given to patients traveling to countries
where polio still occurs. The same advice applies to diphtheria, which is becoming
increasingly common in parts of Eastern Europe.
Tetanus. Maintaining up-to-date protection is vital for individuals whose
employment (e.g., working on a farm) or leisure activity (e.g., gardening) places them at
risk of contracting tetanus.
However, tetanus vaccine can produce side effects in healthy people and may well cause CFS
patients to relapse. The pros and cons need to be carefully considered as tetanus vaccine
has been reported to precipitate CFS.1,2
Typhoid. The typhoid vaccine can cause side effects in healthy people. The
feedback I received from my CFS patients, however, indicates that the oral form of typhoid
vaccine was generally well tolerated.
Whenever vaccinations are considered necessary, they should be given when CFS patients are
feeling reasonably well and not under any undue stress. It is also wise to make sure that
all travel vaccinations are completed at least two weeks before departure in the event a
patient experiences exacerbated symptoms or a relapse.
Not surprisingly, patients with possible vaccine-induced CFS often face considerable
difficulty in obtaining disability benefits on the grounds of permanent ill health.
However, some of my patients in the U.K. have successfully argued their cases and been
awarded injury payments on the grounds that HBV given for occupational health reasons
caused their CFS. I am also involved in a number of cases where the debate is likely to be
settled in court.
References
Lloyd A et al. What is myalgic encephalomyelitis? Lancet. l988; l: 1286-7.
Weir W. The post-viral fatigue syndrome. Current Medical Literature: Infect Dis. l992; 6: 3-8.
CIBA Foundation. Chronic Fatigue Syndrome. Eds. Bock GR et al. J Wiley; l993; symposium 173.
Symmons DPM et al. Can immunisation trigger rheumatoid arthritis? Ann Rheum Dis. l993; 52: 843-844.
Gross K et al. Arthritis after hepatitis B vaccination. Scand J Rheum. l995; 24: 50-2.
Grotto I et al. Major adverse reactions to yeast-derived hepatitis B vaccines—a review. Vaccine. l998; 16: 329-34.
Hyde B. The clinical investigation of acute onset ME/CFS and MS following recombinant hepatitis B immunisation. Second World Congress on CFS and Related Disorders, Brussels. 1999; September 9-12.
Report of the working group on the possible relationship between hepatitis B vaccination and the chronic fatigue syndrome. Canad Med Assoc J. l993; 149: 314-9.
Vedhara K et al. Consequences of live poliovirus vaccine administration in chronic fatigue syndrome. J Neuroimmun. l997; 75: 183-95.
Dr. Charles Shepherd is in private practice in the United Kingdom (U.K.) and is a member of the Chief Medical Officer’s Working Group on CFS/ME at the U.K. Department of Health.