Bell's Palsy and influenza, pneumococcal and hemophilus vaccine

A variety of neurologic complications have been associated with vaccinations (see question below from the archives of Ask the Expert). Facial weakness has been associated with Hepatitis B, measles and both nasal (attenuated) and inactivated influenza vaccinations (1-3). A case-centered analysis in children concluded there was no causal association of influenza vaccination with Bell’s palsy (4).

I searched the Vaccine Adverse Event Reporting System (VAERS) data base using the terms “facial weakness”, “facial paralysis” and “Bell’s palsy” with the pneumococcal and hemophilus vaccines and received no reports.

Rare adverse effects, such as Bell’s palsy, are not easily explained from a pathogenic perspective nor are they predictable. I do not consider the report of Bell’s palsy with recovery following influenza as a contraindication to all other vaccinations. I would communicate this information in a shared decision making discussion and recommend that the benefits of vaccination outweigh the risk in general. However, I am not sure if a 41 year-old healthy male necessarily needs the pneumonia and hemophilus vaccine.

I hope this information is of help to you and your practice.

All my best.
Dennis K. Ledford, MD, FAAAAI

1. Mutsch, Margot, et al. "Use of the inactivated intranasal influenza vaccine and the risk of Bell's palsy in Switzerland." New England journal of medicine 350.9 (2004): 896-903.
2. Chou, Cheng-Hsiu, et al. "Bell's palsy associated with influenza vaccination: two case reports." Vaccine 25.15 (2007): 2839-2841.
3. Zhou, Weigong, et al. "A potential signal of Bell's palsy after parenteral inactivated influenza vaccines: reports to the Vaccine Adverse Event Reporting System (VAERS)—United States, 1991–2001." Pharmacoepidemiology and drug safety 13.8 (2004): 505-510.
4. Rowhani-Rahbar, Ali, et al. "Immunization and Bell’s palsy in children: a case-centered analysis." American journal of epidemiology 175.9 (2012): 878-885.

1/12/2015: Vaccine Reaction with Neurologic Disease
1/6/2015
I have a patient with no past medical history significant for a vaccine reaction or neurological disease. Mom reports that several hours after the DTap (first dose), she had left facial paralysis. It resolved after six hours. She has not received any other vaccines. This was her first vaccine. Mom would like to continue her vaccine schedule.

Neurological complications are associated with a variety of vaccines. These include Guillian Barre syndrome and seizures. Transient weakness of the facial nerve, Bell’s palsy, has been described with Hepatitis B vaccine (Paul R, Stassen FA. Transient facial nerve paralysis (Bell’s palsy) following administration of hepatitis B vaccine: a case report. British Dental Journal 2014;216:69-71). Measles vaccination has been associated with transient facial weakness but the reports are generally 6-8 days after the vaccination. The CDC vaccine website describes seizures, coma, permanent brain damage, encephalopathy and altered consciousness as “very rare” severe complications of the DTaP vaccine but there is no mention of Bell’s palsy. The neurologic complications are likely linked to the pertussis component of the vaccine. Tetanus toxoid has been linked to brachial neuritis and Guillain-Barré syndrome (package insert Daptacel).

Your description of six hours of weakness is not consistent with Bell’s palsy but nevertheless I think the transient weakness could be related to the vaccine. As with any risk/benefit discussion, I would discuss with the child’s parents and document the discussion. The risk of a repeat reaction, if the first episode of facial weakness was related to the vaccine, is much greater than the general population but the occurrence of neurologic complications is very low. Thus, the likelihood of a repeat reaction is possibly as great as 0.5/1000 (risk of neurologic reactions in package insert). The risk of pertussis is probably greater than 2/100,000 (Güris, Dalya, et al. "Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996."Clinical Infectious Diseases 28.6 (1999): 1230-1237).

In summary, I would recommend giving the next scheduled vaccination. I would suggest giving DTaP without other simultaneous vaccines such as inactivated polio, hepatitis, or hemophilus. I would also report the event to the Vaccine Adverse Event Reporting System.

I hope this information is of help to you and your patient.

All my best.
Dennis K. Ledford, MD, FAAAAI