RISKS AND BENEFITS
Few would dispute immunisation of health professionals is a good thing,
both for them and their patients. Yet, as Jane Leeming reports, for some people
immunisations might carry a hidden hazard.
Nurses are frequently encouraged to have immunisations, and would generally be well advised to accept the protection they confer. A number of health workers have claimed however, that adverse reactions to vaccination have resulted in prolonged illness and in some cases inability to return to work. In most of these cases, hepatitis B vaccine has been implicated.
As a student nurse, Hazel was advised to have various vaccinations and in August 1990 had a polio booster and the first of three hepatitis vaccinations. "After about ten minutes I blacked out and was unwell for five weeks" she remembers. "I had ME-like symptoms – exhaustion, muscle fatigue, aches and pains, co-ordination and balance problems and memory loss but they were complicated by the fact that when I blacked out I banged my head and suffered concussion. My employers were not sympathetic".
After re-starting her course two months later, Hazel was encouraged to complete the course of hepatitis B vaccinations. "I was told that if I suffered any reaction to the second one they would let me off the third. I took advice from a GP and was eventually persuaded to have it. I didn’t pass out, but started feeling light-headed after a few hours. After 24 hours I developed balance problems, and soon all the symptoms I’d experienced after the first injection returned". Hazel has since had the diagnosis of ME confirmed, but after more than three years is still unable to do any work and reports no overall improvement.
Exposure-prone procedures
Until now it has been voluntary for health care workers to have a course of hepatitis B vaccinations, although it is recommended that they do so for their own safety. For some workers this could change with the introduction of new health service guidelines – Protecting Health Care Workers and Patients from Hepatitis B – which comes into force for most health care workers in 1999 (?) They state that all health care workers who perform "exposure-prone procedures" should be immunised against hepatitis B and their response to the vaccine subsequently checked.
The purpose is both to protect health care workers who might be at risk of acquiring hepatitis B from a patient, and to protect patients against the risk of acquiring hepatitis B or TB from infected staff.
Strictly interpreted, it should not be compulsory for most GP’s and nurses to be vaccinated, but under the guidelines, non-immunised staff would not be permitted to do certain "exposure-prone procedures". These are defined as where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker. As it is impossible to predict when some of these procedures might need to be carried out, it is possible that staff will be requested to have a course of vaccinations in any case.
It remains to be seen how these guidelines will be implemented by the individual health authorities, trusts and FHSA’s and those workers concerned about the implications for themselves could initially consult their occupational health department or FHSA.
The guidelines have caused concern to a West Midlands GP who prefers not to be identified. He initially developed ME, which lasted two years, after an attack of hepatitis.
"After the ME, I waited until I had been 100% fit for about a year before starting the hepatitis B course, as in my job I am at risk" he says. "Four days after the first injection all the symptoms returned. The vaccination appeared to bring about a complete relapse. I didn’t have any time off to begin with and struggled on for about 18 months, but in the end I had to take a month off, and after that things began to improve".
Three years after the vaccination, the GP believes that he has almost recovered from ME, but is concerned that he might be requested to completed a course of hepatitis B vaccinations by next year. He says, " I have no intention of having a further hepatitis B vaccination and going through another three years of that. I’ve had it twice already".
He believes that the risk of a GP giving hepatitis B to a patient is very remote and is prepared to run the risk, which he believes is small, of acquiring it from a patient.
Dr Charles Shepherd, medical advisor to the ME Association, is convinced of the connection between vaccinations and ME. "I consider that in a small minority of cases a vaccination can be the triggering factor, as can viral infections and possibly some neurotoxins", he says. He believes a vaccination alone can precipitate the illness. " A vaccination mimics the effect of a viral infection, so it is not surprising that it can have the same effect. It is stress on the immune system".
Infective Episodes
From personal experience with patients, he believe tetanus, typhoid and possibly hepatitis B are particularly implicated. "There might be a particular problem with hepatitis B. Many health workers are under enormous pressure to have that vaccine. Although anyone who has contact with blood products would be foolish not to have it, I would advise people with ME, or who have recently recovered, to be extremely cautious about having hepatitis B".
Dr Shepherd has been concerned by cases where people have been given hepatitis B vaccine soon after having glandular fever. "Vaccinations shouldn’t be given when people are recovering from an infective episode" he says, stressing that he is not anti-vaccination. "However, there appears to be a small but significant link, which needs to be looked at".
He is also concerned that adverse reactions are not being reported to the Committee on Safety of Medicines. "These sort of reactions should be going down on yellow cards and being sent in by GP’s and this is not happening".
Dr Elizabeth Dowsett, honorary consultant to the Basildon and Thurrock NHS Health Trust, and president of the ME Association, agrees that an immunisation can precipitate a relapse.
"Your first attack can be after a vaccine but it’s not the vaccine that causes it. You have to have the causal agent of ME in you, an enterovirus. In my experience, any type of vaccine can cause this problem, anything that knocks or disturbs your immune system even temporarily can cause a relapse; any trauma such as an infection or immunisation, an accident or certain drugs. Also physical or mental over-exertion, cold or malnutrition or any chemical substance active in the brain, such as alcohol or general anaesthetic.
You can also be allergic to any vaccine because of the cells in which it was made. The ‘flu vaccine is grown in eggs, so could affect anyone with an egg allergy".
She is particularly concerned about the position of health workers and the hepatitis B vaccine. "Many health care workers have ME, it is one of the highest categories", she says. " We are already discussing the matter with the occupational health service and it should be taken up with the Department of Health".
"First of all, it might be possible to postpone immunisation – although you never know at what point it would be safe. Secondly, many health workers might not actually need it. For example, GP’s have been pressurised to have the hepatitis B vaccine, but don’t actually need it".
Doris Jones has conducted a study of ME for her MSc thesis at the University of East London. He research suggests that a vaccination can trigger the illness, or precipitate a relapse. "About 13 per cent of 225 subjects had been vaccinated in the month before ME onset", she says. She found certain types of vaccine more frequently associated with ME onset, particularly tetanus and, in younger people, BCG.
Although a prior viral or bacterial infection was normally involved, other factors, or combinations of factors, were often implicated. These included the frequent use of antibiotics for recurring infections, stress and exposure to toxic chemical or environmental pollutants.
She agrees that being vaccinated before fully recovering from a viral or other infection might increase the risk of developing a post-viral illness or ME. "My research suggests that there could be an interaction between a viral or other infection and a vaccination. This can occur if someone is vaccinated when they either have a sub-clinical infection or are incubating an infection they are not aware of.
Occasionally it is possible that a vaccination alone can precipitate ME, but it depends on a number of things. Also, certain people might be more at risk of having an adverse reaction, including those who have had a previous reaction to a vaccine, and people with allergies or a suppressed immune system".
Protective Value
In conclusion, the evidence suggests that any vaccine can precipitate ME or a relapse, particularly if other factors are present, such as a viral infection, around the time of the vaccination. It should be emphasised that only a small proportion of cases of ME appear to be precipitated by a vaccine. Most frequently, the illness is preceded by the incomplete recovery from an infection, such as ‘flu.
Health workers face a particular problem, because they are encouraged to have certain immunisations, such as hepatitis B, for their own safety, and the new guidelines will mean certain categories of worker might be required to complete a course of vaccinations.
The protective value of immunisations is indisputable, and undue alarm is to be avoided. However, nurses need to be vigilant for adverse reactions of all kinds among health workers and patients. Many of these might be unreported, so the full extent of the problem is unknown, although doctors are asked to report all suspected reactions to both new and established vaccines to the Committee on Safety of Medicines, so that the balance between risks and benefits can be kept under continuous review.
There is sufficient evidence to suggest that the issue deserves more publicity and research. Will it become possible, for example, to identify in advance those people who might be susceptible to a particular vaccine? In the meantime, it is hoped that this article might give rise to further debate on the issue.
Source: Nursing Standard 1995 vol 9
Jane Leeming is a freelance writer