What should patients who have had GBS be advised about future immunisation?
Sometimes people are advised by their doctor not to have a vaccination within 12 months of having had Guillain-Barré syndrome, as a precaution, so if your diagnosis was very recent, your doctor might advise you to give it a miss this year, unless you are in a group considered to be at high risk from flu.
Otherwise, the advice for people who have had GBS is the same as for anyone else regarding vaccinations. GBS is a single event acute condition that is very unlikely to recur; it doesn’t ‘relapse’ and someone who has had GBS is unlikely to get it again (recurrence rate is believed to be around 2-5%). The only caveat to this would be if you developed GBS within 6 weeks following a vaccination, in which case it would be wise to avoid that particular vaccine in the future. The seasonal flu vaccine changes each year, depending on which strains are predicted by
the WHO to be most prevalent: https://www.who.int/influenza/vaccines/virus/recommendations/en/.
The flu vaccine is also considered safe and advisable for people with CIDP or another of the chronic variants. If you are being treated with immunoglobulins via IVIg or SubCut, you may be less likely to get viral infections, but the best protection from the flu is still to be vaccinated. If you’re being treated with corticosteroids, or other immune-suppressant medication, you may be more prone to viral infections, and a serious case of flu could put you at considerable risk, so again, it would make sense to protect yourself from flu by having a vaccination.
Under normal circumstances, most people don’t need a flu jab, because for them, flu is inconvenient but not life-threatening. However, if you are in an at-risk group, or you live or work closely with people for whom flu can cause severe and even life-threatening complications, then the advice is to be vaccinated, as this is the most effective way to protect yourself against getting
flu, and passing it on to others. This year, things are a bit different, because anyone getting flu and COVID-19 concurrently is potentially at a heightened risk. The flu vaccination programme for 2020/21 is being extended beyond those traditionally considered to be at risk, to minimise the spread and to protect as many people as possible from the associated danger, so it’s worthwhile asking your GP or pharmacist about getting vaccinated, even if you wouldn’t normally be considered at risk.
In the document The national influenza immunisation programme 2020 to 2021 Public Health England states that ‘Previous GBS is not a contraindication to influenza vaccination. A UK study found that there was no association between GBS and influenza vaccines although there was a strong association between GBS and influenza-like illness. A causal relationship between immunisation with influenza vaccine and GBS has not been established.’
This is further supported by the Medicines & Healthcare products Regulatory Agency (MHRA) which states;
‘The balance of epidemiological evidence is not sufficient to confirm that currently used influenza vaccines are causally associated with the development of GBS. As GBS also occurs naturally in the vaccinated population, and particularly because flu-like illness is a known risk factor for GBS, © Guillain-Barré & Associated Inflammatory Neuropathies (GAIN) Registered Charity 1154843 & SCO39900 www.gaincharity.org.uk a number of cases are reported each year in temporal association with vaccination. This does not mean the vaccine was the cause.
Recent data supports the findings made in previous studies that an influenza vaccination may trigger GBS in fewer than 1 in 1,000,000 people vaccinated. There were approximately 14,000,000 people vaccinated in the UK during 2019/20 and there were 11 reports submitted through the yellow card scheme for the same period.
It should be understood that these may be true side-effects, or they may be due to concurrent diagnosed or undiagnosed illness, other medicines or they may be purely co-incidental events that would have occurred anyway in the absence of therapy. Based on current evidence, the MHRA findings are that these reports do not indicate a causal relationship between influenza
vaccine and GBS.’
GAIN would also add that this is supported by independent research showing colds and flu-like illnesses to be known triggers for GBS. Because vaccines stimulate the immune system, theoretically this might exacerbate or lead to the appearance of an autoimmune disease, but it is not possible to identify those for whom a vaccine might act as a trigger, or why. The seasonal flu
vaccination is considered to be a very low risk trigger, with approximately 1 case of GBS per 1,000,000 vaccinations as opposed to 1 case of GBS per 60,000 cases of flu.
It is difficult to comment on the many COVID-19 vaccines that are currently under development, as they are still in various stages of being tried and tested, but it would seem feasible that similar advice would follow. In this case, however, we know that unlike flu, only around 20% of people who test positive for COVID-19 actually show symptoms, and that as well as amongst high risk
groups, COVID-19 can be fatal in younger people and people without co-morbidities who would not normally be considered at risk. The advice, once vaccines are available, will probably be for the at greatest risk to receive it first, followed by the rest of the population, as this is the most effective way to limit spread and protect the most vulnerable.
On vaccinations in general, our Medical Advisory Board would offer the following advice:
• DON’T have a vaccine that was temporally associated with your onset of GBS (i.e. within about 6 weeks)
• DON’T have unnecessary vaccines for travel but DO have all travel vaccines that are recommended for the particular area you are travelling to
• DO have all vaccines that are ‘necessary’. This includes the flu vaccine (if you are in an at risk group), MMR, DTP, pneumovax, HIF etc., and will include COVID-19 vaccine when it becomes available. There is no population link to causation in any of these – there are monitoring programmes going on so a link would be picked up if it occurred; no links have been detected since the 1970s
Vaccines currently in use are amongst the safest medicines available. However, as with many things in life, there is no simple ‘yes or no’ answer, and each person must weigh up the risks associated with not having a vaccination, against the very small risk that might be associated with having it. Hopefully, this information will help you reach an informed decision
Statement from a Medicines and Healthcare products Regulatory Agency (MHRA) spokesperson:
Every year, more than eight million doses of flu vaccine are administered across the UK to those aged 65 years and over, with millions more given to healthy younger people and those at higher risk of flu.
As Guillain-Barré syndrome (GBS) can occur naturally across all age groups, and with such high exposure to flu vaccines, it is inevitable that there will be a few cases of GBS after a flu vaccination is given. This association does not necessarily mean the vaccine is the cause. Indeed, for every million people aged 65 years and over who have the vaccine each year, we expect three cases of GBS to occur within six weeks of vaccination by coincidence alone.
Suggestions that flu vaccines may cause GBS can be pinpointed to a very specific type of vaccine given to patients in the USA in 1976. The vaccine was not used in any other countries and a theory was that this risk was due to a contaminant in that particular type of vaccine.
Since then, numerous population-based studies in many countries have looked at whether currently-used flu vaccines may also be a cause of GBS. A couple of these studies have suggested that if there was an association, it would be an extremely small risk – in the order of one case for every million people vaccinated. However, most studies have found no association and, taken together, the evidence is far more suggestive of there being no causal association between flu vaccination and development of GBS.
A review of vaccines and GBS was recently published, which considers this in further detail: https://www.sciencedirect.com/science/article/pii/S0264410X18307989?via%3Dihub. On the other hand, there is good evidence to show that flu-like illness is associated with an increased risk of GBS (https://www.ncbi.nlm.nih.gov/pubmed/19033158), suggesting that flu vaccination may actually protect people from GBS.
If you would like to report a suspected side effect you have experienced after taking a medicine or vaccine, including the flu vaccine, then we would encourage you to do so either via the Yellow Card website https://yellowcard.mhra.gov.uk/ or download the free Yellow Card mobile app from iTunes Yellow Card for iOS or Playstore Yellow Card for Android devices.