GUIDE

Immunisation Notes

This series of guides is produced by the Guillain-Barré Syndrome Support Group. We are a registered charity that supports those affected by the Guillain-Barré syndrome (GBS) and related conditions in the United Kingdom and the Republic of Ireland. The related conditions include chronic inflammatory demye-linating polyradiculoneuropathy (CIDP) and Miller Fisher syndrome (MFS).

Our guides are easily downloaded from our Web site at www.gbs.org.uk in PDF format and may be both read and printed using free Adobe Reader software. Al-ternatively, you can request printed copies from our office.

GBS Immunisation Notes

• CIDP immunisation notes – see below.

• This text has been agreed by members of the Group's Medical Advisory Board. This guide is offered in response to continual requests for advice on immunisations and is subject to our usual disclaimer.

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 United States 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 con-trols.8-10 Retrospective examination of the incidence of GBS for the seasons of the 1992-1993 and 1993-1994 influenza vaccination programs in the United States suggested that influenza vaccination only caused one to two 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 in-fluenza vaccine.14 In addition recurrent attacks of chronic inflammatory demye-linating polyradiculoneuropathy 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 ade-quately 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 immunisa-tion adversely effects the course of multiple sclerosis. In the case of influenza vaccine and hepatitis B vaccines this conclusion was based on large epidemiol-ogical studies.

Conclusion

1. In patients who have previously had GBS recurrence of GBS after immunisa-tion is rare.

2. The need for a particular immunisation requires careful evaluation on an indi-vidual basis.

3. Immunisations should not be performed during the acute phase of GBS and should probably be avoided until at least one year after the onset of the disease.

4. If GBS occurred within six weeks after an immunisation, the patient should not receive that immunisation again.

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 fol-lowing 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 syn-drome. 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 ru-bella 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 Acad-emy 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 syn-drome. 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. Immuni-sation 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 syn-drome. New Engl J Med 1998;339:1845-6.

14. Seyal M, Ziegler DK, Couch JR. Recurrent Guillain-Barre syndrome follow-ing 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 re-lapse 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 im-munization 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.

CIDP Immunisation Notes

This text has been agreed by members of the Group's Medical Advisory Board. This page is offered in response to continual requests for advice on immunisa-tions and is subject to our usual disclaimer.

What should patients who have or have had chronic inflammatory demyeli-nating polyradiculoneuropathy be advised about future immunisations?

What is chronic inflammatory demyelinating polyradiculoneuropathy?

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease of the peripheral nervous system causing weakness and numbness. It is probably due to a disorder of the immune system causing inflammation in the peripheral nerves. It may last months or years. It may get better on its own. Neurologists of-ten prescribe steroids, intravenous immunoglobulin or immunosuppressive drugs.

How do immunisations work?

Immunisations, also called vaccinations or vaccines, are injections of bacteria or viruses that have been altered to protect people from infections instead of causing them. They do this by stimulating the immune system.

Examples are:

• tetanus vaccine to prevent tetanus

• measles mumps and rubella (MMR) vaccine to prevent measles, mumps and rubella (German measles)

• influenza vaccine to prevent influenza

Influenza immunisation

In the UK the Department of Health recommends influenza vaccine for those who are 65 years or older and those with:

• Chronic lung disease including asthma

• Chronic heart disease

• Chronic renal failure

• Immunosuppression due to disease or treatment

Vaccines in CIDP

Little is known about the risks of immunisation in CIDP. There have been reports of relapse of CIDP soon after immunisation for tetanus in three patients.^1,2

In 2002 members of the GBS Support Group answered a questionnaire.³ Sixty five people with CIDP said that they had received vaccines. Sixty had had no problems. Five (8%) said they got worse afterwards. Three (5%) of these said that their symptoms were like a typical relapse of their CIDP. One needed treatment. The other two were already getting neurological symptoms before the immunisa-tion so that the immunisation may not have been to blame. It is difficult to say whether any of these immunisations really caused the relapses. They could have been coincidental. However it is impossible to deny that relapses sometimes hap-pen after immunisations in CIDP. The answers to this questionnaire suggest that the risk lies between 2.5 and 17%. However questionnaires like this often overes-timate the risk so that the real risk is probably less and might be much less.

In many other neurological diseases, for instance multiple sclerosis, there is more information and influenza vaccine is considered safe.

What should I do?

This always depends on your individual circumstances. You must balance the benefits of the vaccine against the unknown but probably small risk of the vac-cine causing a relapse.

You should always discuss this with your own doctor. Ask your doctor if the vaccine is really necessary. The following are common questions:

1. I am NOT on steroids, plasma exchange, azathioprine or other immu-nosuppressive drugs: should I be immunised? Some immunisations are more important than others. For example, most people have already been immunised against tetanus, and boosters may not be essential. However if you have not been immunised within the past 5 years and cut yourself so that dirt gets into the wound then the balance of risks may change in favour of receiving the vaccine.

2. I AM on steroids, azathioprine or other immunosuppressive drugs: should I be immunised? Theoretically your risk of developing infections like a serious case of influenza is greater because you are on these drugs. However your risk of having a relapse of CIDP is also probably less be-cause you are on them. The balance of evidence may therefore be more in favour of having, for instance, an annual influenza vaccine.

3. I am on intravenous immunoglobulin: should I be immunised? Intrave-nous immunoglobulin probably makes you less likely to have infections so the need for immunisation is less. Also intravenous immunoglobulin probably makes immunisations less effective. If you decide to be immu-nised, theoretically it is probably better to do this half way between your in-travenous immunoglobulin courses. Reminder The decision to have a vac-cine depends on your individual circumstances and you should always dis-cuss this with your own doctor. You might wish to show him or her a copy of this guideline.

References

1. Pollard JD, Selby G. Relapsing neuropathy due to tetanus toxoid. J Neurol Sci 1978; 37:113-125.

2. Hughes RAC, Choudhary PP, Osborn M, Rees JH, Sanders EACM. Immu-nisation and risk of relapse of Guillain-Barré syndrome or chronic inflam-matory demyelinating polyradiculoneuropathy. Muscle Nerve 1996; 19:1230-1231.

3. Pritchard J, Mukherjee R, Hughes RAC. The Risk of Relapse of Guillain-Barré Syndrome or Chronic Inflammatory Demyelinating Polyradiculo-neuropathy following Immunisation. J Neurol Neurosurg Psychiatry 2002; 73:348-349.

Page updated December 2003

If after reading this guide you still have anxieties and unanswered questions, telephone our helpline on 0800 374803 (UK) or 0044 1529 415278 (RoI). Alter-natively, you can e-mail us or register for support on-line.

The GBS Support Group is a registered charity and receives neither government nor Lottery funding. If you have found this guide helpful and would like to help us to continue publishing copies for others affected by GBS and its related condi-tions, please consider making a donation to the Support Group. Secure donations may be made on line. Alternatively you can request a form from our office

GBS Support Group, LCC Offices, Eastgate, Sleaford, Lincs, NG34 7EB

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