Does a history of having contracted Guillan Barré syndrome (GBS) preclude someone from receiving certain vaccines? Which vaccines do you have to worry about? What is the evidence for a causal connection?
In the following scenario, see if you think a contraindication is present.
A 12-year-old is in your office and needs a Tdap, HPV, inactivated flu shot, and quadravalent meningococcal vaccine. Her medical history is significant for GBS that began 4 weeks after she received Tdap, MMR, IPV, LAIV, and Varivax at age 5. She has recovered fully.
The correct answer is D. Neither A nor B is true but are considered precautions, not contraindications.
The GBS-flu vaccine concern stems from the 1976 swine flu vaccine that was rushed to market and given to over 45 million Americans in a 3-month period out of fear that this novel H1N1 strain, closely related to the 1918 pandemic strain, would cause the next flu pandemic. As it turned out, other than a few military recruits at Fort Dix in New Jersey, no one else became ill. Surveillance data picked up an increase in GBS above the expected background rate in vaccine recipients of about 1 in 100,000 vaccine recipients. The scientific plausibility of this being real was heightened when mice were shown to have developed antiganglioside antibodies after being given this vaccine. Anti-ganglioside antibodies have been demonstrated in multiple human autoimmune neuropathies, including GBS.1 On a personal note, the 1976 flu vaccine was the first flu vaccine I ever received and I have had one every year since.
Since 1976, multiple studies have looked for a flu vaccine-GBS connection.2-5 Most show no increased risk above the background rate (80-160 new cases per week in the US). Some suggest there may be an increased risk in the range of 1 new case per one million vaccine recipients. Some researchers have shown a protective effect of the flu vaccine on development of GBS since influenza illness has been associated with a slight increased risk of GBS.
Menactra (MCV4-D) was licensed in 2005 and within 9 months, 17 cases of GBS were reported through VAERS. Most occurred within a time frame suggestive of a causal effect. (On another personal note, I reported one of those 17 cases involving a 16-year-old who was diagnosed with GBS about 3 weeks after vaccine receipt. And, no, my nickname is not Forrest Gump.) This led the CDC to list GBS as a precaution for meningococcal vaccines. Subsequent studies of millions of individuals did not show any increase above the background rate. In 2010, the CDC removed the warning.
Three vaccines that have been tied to GBS include the older forms of rabies vaccine grown in mammalian brain tissue cultures. Current rabies vaccines are grown in chick embryo cultures and have not been associated with an increased risk of GBS. Oral polio and tetanus toxoid-containing vaccines were implicated in case reports and again follow up studies were mostly inconclusive in showing a causal relationship. Nevertheless, a history of GBS is still considered a precaution for tetanus-containing vaccines.
So, back to our scenario of the 12-year-old needing a Tdap: the VIS sheet lists history of GBS as a precaution. Before you order the vaccine, you should have a discussion with the mother about what that means. It is not contraindicated, it is in the precaution category. If you feel the benefit outweighs the risk, then you should recommend the vaccine. I would.
- Nobuhiro Y. Guillain–Barré syndrome and anti-ganglioside antibodies: a clinician-scientist’s journey. Proc Jpn Acad Ser B Phys Biol Sci. 2012;88:299–326.
- Guillain-Barré syndrome and Flu Vaccine. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/protect/vaccine/guillainbarre.htm
- Hurwitz ES, Schonberger LB, Nelson DB, Holman RV. Guillain-Barré syndrome and the 1978–1979 influenza vaccine. N Engl J Med. 1981; 304:1557-1561. (This study showed no relation between GBS and the flu vaccine.)
- Tam CC, O'Brien SJO, Petersen I, et al. Guillain-Barré syndrome and preceding infection with Campylobacter, Influenza and Epstein-Barr Virus in the general practice research database. PLOS One. April 4, 2007. https://doi.org/10.1371/journal.pone.0000344 (This study suggests that flu vaccine may protect against GBS.)
- Haber P, Sejvar J, Mikaeloff Y, DeStefano F. Vaccines and Guillain-Barré syndrome. Drug Saf. 2009;32:309-323. https://www.ncbi.nlm.nih.gov/pubmed/19388722 (This author believes only the swine flu vaccine showed any increase risk of GBS.)