Measles Vaccines Reactions - GBS

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GUILLAIN-BARRÉ SYNDROME
Clinical Description
Guillain-Barré syndrome (GBS) is characterized by the rapid onset of
flaccid motor weakness with depression of tendon reflexes and inflammatory
demyelination of peripheral nerves (Asbury and Gibbs, 1990). The annual
incidence of GBS appears to be approximately 1 per 100,000 people for
adults. The data are not definitive, but the annual incidence of GBS in
children under age 5 years appears to be approximately the same. The annual
incidence of GBS in children over age 5 years and teenagers appears to be
lower. Chapter 3 contains a detailed discussion of GBS.

History of Suspected Association
A possible relation between live attenuated viral vaccines and
demyelinating disease has been investigated for many years, as described in
Chapter 3. There is no specific information suggesting an association
between measles vaccine and GBS. The committee was charged with
investigating a possible causal relation between only measles vaccine and GBS.

Evidence for Association
Biologic Plausibility
Chapter 3 contains a detailed discussion of the arguments that vaccine can
cause demyelination, including GBS. GBS has been described in a few
patients following natural (wild-type) measles infection (Lidin-Janson and
Straanegard, 1972). Thus, GBS appears to be a rare but possible sequela of
measles.

Case Reports, Case Series, and Uncontrolled Observational Studies
Grose and Spigland (1976) reported two cases of GBS that developed in
patients within 1 week after immunization with measles vaccine. One of
these patients, a 19-month-old girl, was part of a study of 24 patients
with GBS for whom serologic studies were performed as part of an effort by
the authors to identify possible causal viral agents. She received a
combined measles (Moraten strain) and rubella vaccine 5 days before the
development of symptoms (unable to stand and support her own weight). The
authors eliminated the possibility that the neuralgic reaction was unlikely
to be related to rubella vaccine, because the rubella virus titers
indicated that the child was already immune to rubella virus when she was
given the vaccine. Four years later the authors saw a second patient with
characteristics similar to those of their first one. A 10-month-old girl
was given measles vaccine (Moraten strain), as well as her second doses of
DPT and OPV, and 4 days later she developed early symptoms of GBS. Both
children had a primary immune response to measles antigen, as demonstrated
by the seroconversion following immunization.

Norrby (1984) described a 12-year-old girl who became ill with a disorder
diagnosed as GBS soon after being vaccinated with MMR, but her CSF protein
levels were normal, which casts doubt on the diagnosis. The other findings
were supportive of a diagnosis of GBS. The authors presented summary data
from Merck Sharp & Dohme indicating that 1 in 60 million doses of MMR has
been associated with GBS. Landrigan and Witte (1973) used data voluntarily
submitted to the Center for Disease Control regarding neuralgic disorders
following administration of measles vaccine. From 1963 to 1971, 84 cases of
neuralgic disorders with onset less than 30 days after live attenuated
measles virus vaccination were reported in the United States, but these did
not include GBS. In a review of adverse event reports submitted between
1976 and 1989 to the Behringwerke AG pharmaceutical firm in the former West
Germany, Fescharek and colleagues (1990) described three cases of GBS
following vaccination with measles or mumps vaccines (the specific vaccines
used in the three patients were not identified). Two of the cases were
thought to be related to something other than the vaccines; however, this
was not elaborated. Assuming that all three cases were causally related,
the authors calculated an incidence of 1 in 1.8 million doses of vaccine
distributed.

Summary data from MSAEFI record eight cases of GBS following measles
immunization reported between 1979 and 1990. One patient received
measles-rubella vaccine and seven received MMR. Nine VAERS reports
(submitted between November 1990 and July 1992) reviewed by the committee
describe the occurrence of GBS after measles immunization. Three of the
five VAERS reports indicating the occurrence of GBS after vaccination with
MMR alone met the diagnostic criteria for GBS as outlined in Chapter 3. The
patients reported in the other four reports received other vaccines in
addition to MMR.

Controlled Observational Studies
None.

Controlled Clinical Trials
None.

Causality Argument
There is biologic plausibility for a causal relation between measles
vaccine and GBS. GBS has been shown to follow natural measles virus
infection. As described in Chapter 3, several vaccines and viruses are
suspected of playing a role in GBS. Reports in the literature describing a
possible relation between GBS and measles vaccine are case reports, case
series, and uncontrolled observational studies. These include at most a
total of six cases of GBS reported in the published literature and seven
cases from VAERS. These cases were temporally related to vaccination;
however, lack of clinical details and other antecedent events preclude a
determination of a causal relation.

Conclusion
The evidence is inadequate to accept or reject a causal relation between
measles vaccine and GBS.