There is widespread agreement that a variety
of infections are capable of precipitating
chronic fatigue syndrome (CFS) in susceptible individuals. In l988, Lloyd et al reported that several
of their patients had linked the onset of CFS to receiving a vaccination in the absence of any coincidental
infection.l Since then, other anecdotal reports have also linked vaccinations to the onset
The explanation for vaccine-induced CFS may be because the primary purpose
of any vaccine is to mimic the effects of infection on the immune system. If an antigenic challenge by
infection can precipitate CFS, then it is conceivable that vaccines could act in a very similar manner.
reasoning is further strengthened by the fact that immunologically based illnesses, such as arthritis,
can occur when a susceptible host and an environmental trigger, such as an infection or vaccination, interact.4
It is also interesting to note that vaccinations have been suggested as a possible precipitating factor
in the development of Gulf War illness.
My research interest
in this aspect of developing
CFS is largely based on clinical evidence from patients seen in my practice over the past 10 years. As
a result, I have gathered details on more than 200 patients with a history of either developing CFS or
experiencing a significant relapse/exacerbation of CFS symptoms following a vaccination.
I have more than 150 reports referring to such a link from members of myalgic enceph-alomyelitis (ME)
or CFS self-help support groups and/or their physicians throughout the world.
This data (although
unpublished) suggests that tetanus, typhoid, influenza, and hepatitis B are the most commonly implicated
vaccines in cases of CFS. I have reports of very few cases involving hepatitis A (using immunoglobulin),
polio, or rubella vaccine, or those predominantly given during childhood—-with the possible exception
of Bacillus Calmette--Guerin vaccine (three cases).
Almost all of my cases involve adults, and
in a significant minority the vaccine was administered when the person had not yet fully recovered from
an infective illness such as infectious mononucleosis (known as glandular fever in the U.K.) or had already
experienced an adverse reaction to a previous dose of the same vaccine (as is sometimes the case with
hepatitis B accine).
About one third of my cases involve vaccine-induced/exacerbated CFS following
receiving the hepatitis B vaccine (HBV). Most of these patients are health care workers, particularly
nurses. Most of the other patients received HBV for occupational health purposes, often as a condition
of employment and without any information on side effects, such as severe neurological reactions.
prognosis in this group has been poor, with less than 10% of the patients I have personally followed reporting
any significant relief of CFS symptoms.
Although chronic debilitating fatigue is the most frequently
reported symp-tom of CFS after vaccine administration in this group, around 20% also complained of significant
joint pain/arthralgia, a finding consistent with several reports linking HBV to arthritis and other autoimmune
Less than 5% of the patients also reported neurological complications/side
effects such as tremors or one-sided weakness, which appear to be separate from their CFS symptoms.
instance, one female patient developed an acute disseminated inflammation of the brain and spinal cord
(encephalo-myelitis) shortly after the second dose of vaccine. This was followed by the gradual onset
Hepatitis vaccines are highly immunogenic compounds, and a number of possible explanations
exist as to why they may be more likely to trigger CFS.
One explanation involves a preexisting
genetic susceptibility, which after antigenic stimulation with HBV, results in a pathological process
(possibly involving immune complex formation) leading to a clinical disease.
is that a hypersensitivity reaction occurs to a component of HBV, such as the preservative thimerosal.6
in Canada, who made similar observations of a link between HBV and CFS, hypothesized that this may involve
an autoimmune reaction with a microscopic form of demyelination not visible on magnetic resonance imaging.7
growing anecdotal evidence from other experienced physicians who also believe that HBV can precipitate
CFS,2 vaccine manufacturers do not acknowledge any causal link. In fact, a report by an independent
working group in Canada that dismissed any such causal link is frequently quoted as a reason for dismissing
these claims, even though it contained some very questionable assumptions to support the conclusions.8
example, the report inaccurately states that chronic carriers of hepatitis B infection without signs of
ongoing liver damage do not complain of tiredness. The report also uses results from a one-week follow-up
study of 700 health care students, which found excessive short-term tiredness in about 14% after vaccination
with HBV to refute any link with chronic fatigue.
Health care providers
caring for CFS patients who
require vaccinations clearly must weigh the pros (i.e., how effective? how necessary?) and cons (i.e.,
risks of adverse effects and exacerbation of CFS symptoms) for each individual vaccine. I would advise
against having routine nonessential vaccinations if a patient is:
If the vaccination is potentially lifesaving,
then considerations relating
to CFS must take a lower priority. As for some of the more commonly required vaccines, my advice on their
use is as follows:
Hepatitis A. Short-lived protection using immuno-globulin does not
seem to cause any problems in CFS patients. I have not received any adverse feedback from CFS patients
who have used hepatitis A vaccine.
Hepatitis B. If a patient requires HBV for occupational
health purposes, clinicians should weigh the pros and cons as previously discussed and then discuss with
Influenza. If a patient has any medical condition that could be severely
affected by an attack of the flu, such as heart disease, asthma, or bronchitis, influenza vaccine should
certainly be considered.
My own data indicates approximately 60% of CFS patients experience some
form of exacerbation in their fatigue and flulike symptoms (sometimes quite marked) following an
Meningitis C. My feedback from approximately 30 children and adolescents
with CFS who have been given the meningitis C vaccine in the U.K. is that there were no serious side effects
or exacerbations of CFS symptoms. The only adverse effects reported have been minor exacerbations of fatigue
Polio and diphtheria. One research study showed evidence that people with
CFS do not experience adverse reactions to polio vaccination.9 This is also my own impression
from feedback received from patients I have advised receive polio boosters in relation to foreign travel.
Polio vaccinations or boosters should clearly be given to patients traveling to countries where
polio still occurs. The same advice applies to diphtheria, which is becoming increasingly common in parts
of Eastern Europe.
Tetanus. Maintaining up-to-date protection is vital for individuals
whose employment (e.g., working on a farm) or leisure activity (e.g., gardening) places them at risk of
However, tetanus vaccine can produce side effects in healthy people and may
well cause CFS patients to relapse. The pros and cons need to be carefully considered as tetanus vaccine
has been reported to precipitate CFS.1,2
Typhoid. The typhoid vaccine can cause
side effects in healthy people. The feedback I received from my CFS patients, however, indicates that
the oral form of typhoid vaccine was generally well tolerated.
Whenever vaccinations are considered
necessary, they should be given when CFS patients are feeling reasonably well and not under any undue
stress. It is also wise to make sure that all travel vaccinations are completed at least two weeks before
departure in the event a patient experiences exacerbated symptoms or a relapse.
patients with possible vaccine-induced CFS often face considerable difficulty in obtaining disability
benefits on the grounds of permanent ill health. However, some of my patients in the U.K. have successfully
argued their cases and been awarded injury payments on the grounds that HBV given for occupational health
reasons caused their CFS. I am also involved in a number of cases where the debate is likely to be settled
Lloyd A et al. What is myalgic encephalomyelitis? Lancet.
l988; l: 1286-7.
Weir W. The post-viral fatigue syndrome. Current Medical Literature:
Infect Dis. l992; 6: 3-8.
CIBA Foundation. Chronic Fatigue Syndrome. Eds. Bock GR et al. J
Wiley; l993; symposium 173.
Symmons DPM et al. Can immunisation trigger rheumatoid arthritis? Ann
Rheum Dis. l993; 52: 843-844.
Gross K et al. Arthritis after hepatitis B vaccination. Scand J Rheum.
l995; 24: 50-2.
Grotto I et al. Major adverse reactions to yeast-derived hepatitis B vaccines—a
review. Vaccine. l998; 16: 329-34.
Hyde B. The clinical investigation of acute onset ME/CFS and MS following
recombinant hepatitis B immunisation. Second World Congress on CFS and Related Disorders, Brussels. 1999;
Report of the working group on the possible relationship between hepatitis
B vaccination and the chronic fatigue syndrome. Canad Med Assoc J. l993; 149: 314-9.
Vedhara K et al. Consequences of live poliovirus vaccine administration in
chronic fatigue syndrome. J Neuroimmun. l997; 75: 183-95.
Dr. Charles Shepherd is in private practice in the United Kingdom (U.K.)
and is a
member of the Chief Medical Officer’s Working Group on CFS/ME at the U.K. Department of Health.