Dr Charles Shepherd (Letter to BMJ, Sept 9, 1996)

Antigenic challenges by infection and vaccination have both been implicated as precipitating factors in the development of chronic fatigue syndrome(CFS).1 Although it has recently been suggested that infection with hepatitis B virus may be more likely to result in CFS than other types of infection 2, there are contradictory reports about the possible role of hepatitis B vaccination.

I wish to report some preliminary findings on a cohort of 91 CFS patients where the outset or a significant degree of relapse appears to have been associated with vaccination. Of particular interest is the fact that 50% (54/91) of these cases involve vaccination against hepatitis B.

The hepatitis B vaccination subgroup were all immunised between 1987 and 1996. Onset of chronic debilitating fatigue and various other symptoms commonly associated with CFS coincided with or occurred shortly after one or more doses of hepatitis B vaccine. Seven of this subgroup also reported arthralgia – a finding which is consistent with an earlier report linking this vaccine with reactive arthritis.4

The vast majority of this subgroup (41/54) are health care workers particularly nurses. The remainder were also immunised for occupational purposes or foreign travel. Overall, the prognosis has been poor with very few reporting complete recovery. Several have had to terminate their employment and apply for early retirement.

Of concern is the fact that (a) several health workers reported that they were persuaded to continue with their vaccination course despite the fact that they did not appear to be fully recovered from an adverse reaction (eg general malaise) following the first or second dose, (b) very few of these adverse reactions have been reported to the Committee on Safety of Medicines and (c) the manufacturers acknowledge that individual adverse reactions can include fatigue, myalgia, arthralgia, headache, insomnia and lymphadenopathy but refuse to accept that any causal link has been established with a combination of the above (ie CFS).

If viral infections are capable of precipitating CFS then it seems feasible that vaccines – which act by mimicking the effect of infection on the immune system – could also be involved. One possible explanation for the apparent bias towards hepatitis B vaccine is that it is a highly immunogenic compound (containing thiomersal and a preservative) which has already been linked to a variety of immunological hypersensitivity reactions. 5

Effective protection against hepatitis B is a necessary precaution which should undoubtedly be encouraged amongst high risk occupational groups. However, CFS may be an important adverse reaction in susceptible individuals.



  1. Lloyd A R, Wakefield D, Boughton C, Dwyer J, What is myalgic encephalomyelitis? Lancet 1988: 1: 1286-1287
  2. Berelowitz GJ, Burgess A P, Thanabalsingham T, Murray-Lyon I M, Wright D J M. Post-hepatitis syndrome revisited. Journal of Viral Hepatitis 1995; 2: 133-138
  3. Delage G, Salit I, Pennie R, Alary M, Duval B. Report of the Working group on the possible relationship between hepatitis B vaccination and chronic fatigue syndrome. Canadian Medical Association Journal 1993; 149: 314-316
  4. Hassan W, Oldham R. Reiter’s syndrome and reactive arthritis in health care workers after vaccination. British Medical Journal 1994; 309: 94

5 Mayboom R H B, Fucik H, Edwards I R. Thrombocytopenia reported in association with hepatitis B and A vaccines. Lancet 1995; 345: 1638

Myalgic Encephalomyelitis Association, 4 Corringham Road, Stanford le Hope, Essex SS17 OAH. Tel: 01375 642466

[Vaccination]  [CFS/ME & vaccines]