Human papillomavirus (HPV) vaccine and autonomic disorders: a position statement from the American Autonomic Society

  • Alexandru BarboiEmail author
  • Christopher H. Gibbons
  • Felicia Axelrod
  • Eduardo E. Benarroch
  • Italo Biaggioni
  • Mark W. Chapleau
  • Gisela Chelimsky
  • Thomas Chelimsky
  • William P. Cheshire
  • Victoria E. Claydon
  • Roy Freeman
  • David S. Goldstein
  • Michael J. Joyner
  • Horacio Kaufmann
  • Phillip A. Low
  • Lucy Norcliffe-Kaufmann
  • David Robertson
  • Cyndya A. Shibao
  • Wolfgang Singer
  • Howard Snapper
  • Steven Vernino
  • Satish R. Raj
  • on behalf of the American Autonomic Society
Research Article



Human papillomavirus (HPV) vaccination has been anecdotally connected to the development of dysautonomia, chronic fatigue, complex regional pain syndrome and postural tachycardia syndrome.


To critically evaluate a potential connection between HPV vaccination and the above-noted conditions.


We reviewed the literature containing the biology of the virus, pathophysiology of infection, epidemiology of associated cancers, indications of HPV vaccination, safety surveillance data and published reports linking HPV vaccination to autonomic disorders.


At this time, the American Autonomic Society finds that there are no data to support a causal relationship between HPV vaccination and CRPS, chronic fatigue, and postural tachycardia syndrome to other forms of dysautonomia.


Certain conditions are prevalent in the same populations that are vaccinated with the HPV vaccine (peri-pubertal males and females). This association, however, is an insufficient proof of causality.


Consensus statement Postural tachycardia syndrome HPV Vaccine Autonomic dysfunction 

Impact of human papilloma virus on human health

Human papillomaviruses (HPV) are non-enveloped viruses with a double-stranded circular DNA genome. The genome is enclosed in an icosahedral capsid, which is made up of two proteins: the major capsid protein (L1) and the minor capsid protein (L2). HPV is the most common sexually transmitted infection in the USA. An estimated 14 million persons are newly infected with HPV each year in the USA with nearly half occurring in adolescents and young adults [1]. Although HPV infection is common (40–80% lifetime probability of infection) [2], most infections are cleared by a cell-mediated immune response [3].

Epidemiological data support the existence of a group of high-risk human papilloma viruses associated with cancer: HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 [3, 4]. These high-risk viruses cause dysfunction of cell cycle regulators and cause neoplasia [3, 5]. Inability of the immune system to clear this high-risk infection is another hypothesized pathway leading to cancer [6]. HPV infection causes cancers at transformation zones between different kinds of epithelium: cervix, anus, and oropharynx [7]. In addition to oncogenic HPV infection, concomitant sexually transmitted diseases, multiparity, smoking, and hormonal contraceptive use are other identified risk factors for cervical cancer [7]. There is a severity-dependent infection prevalence: tests for HPV DNA are positive in 11.7% with normal cervical cytology, 50–70% of cervical intraepithelial neoplasia (CIN) 1, 85% of CIN 2, 90–100% of CIN 3, 85% of vaginal cancer, 80–96% of anal cancer, 40–70% of invasive penile cancer, and 72% of squamous cell head and neck cancer [3, 4].

Infection with HPV is recognized as one of the major causes of infection-related cancer worldwide [8]. Persistent oncogenic HPV infections cause over 500,000 cancers worldwide and 30,000 cancers [7, 9, 10] in the USA annually, with more than half of those cases leading to death [11]. Cervical cancer is the fourth most common cancer in women and the second largest cause of mortality from cancer in the developing world [11, 12, 13, 14, 15]. HPV also has a major role in the etiology of squamous cell carcinoma of the anus (men and women), vulva, vagina, penis, mouth, and oropharynx [16, 17, 18].

Current approach to treatment of HPV-related diseases

Education, abstinence, and condom use can all reduce infection risk, but even strict condom use is not completely protective in males [7]. Current treatments cannot eliminate HPV, thus contributing to high infection prevalence [4].

HPV vaccination is effective in preventing infection and thus development of high-grade precancerous lesions [7, 19]. Phase III randomized controlled trials of prophylactic HPV vaccination were designed to prevent incident-related HPV infection and thus pre-neoplastic lesions [20, 21]. All vaccines demonstrated high immunogenicity and efficacy in preventing persistent infection (90% infection reduction, 90% reduction in genital warts) and precancerous (CIN3) lesions (85% reduction) [20]. This makes HPV vaccination a high-value public health intervention [8].

Three HPV vaccines licensed in the USA (Cervarix, Gardasil, and Gardasil 9) protect against infection with HPV types 16 and 18 which cause over 60% of cervical and oropharyngeal HPV-related cancers. In addition, quadrivalent (Gardasil) and nonavalent (Gardasil 9) HPV vaccines protect against HPV types 6 and 11, which cause 90% of genital warts, and Gardasil 9 protects against five additional oncogenic HPV serotypes. These vaccines are composed of virus-like particles (VLPs) derived from the major capsid protein (L1) of HPV, contain no genetic viral material, and are highly immunogenic. All three available vaccines are most effective in preventing HPV-related disease in naïve patients only and ideally should be administered before onset of sexual activity. As the vaccines induce humoral immunity and not cell-mediated immunity, they have no therapeutic effect in patients who already have genital lesions or HPV-related cancer [19].

On the basis of phase III trial data, in 2006, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended routine vaccination of females 11–12 years of age and catch-up vaccination of females 13–26 years of age with a series of three doses of Gardasil given at baseline, 1–2 months after initiation, and 6 months after initiation [13]. Routine Gardasil vaccination of males 11–12 years of age, with catch-up vaccination of males 13–21 years of age, was recommended by the ACIP in 2011 [22]. The US Food and Drug Administration (FDA) licensed the nonavalent Gardasil vaccine in 2009 for females and in 2014 for males [23]. Given the high immunogenicity of Gardasil among males (97.4–99.2% seroconversion at 7 months) [24] and suboptimal vaccination coverage among females, HPV vaccination of males benefits females through herd immunity [23]. Furthermore, HPV vaccination will play an important role in stemming the increasing incidence of HPV-related oropharyngeal cancers in males which is expected to exceed that of cervical cancer in the USA by 2020 [22].

HPV vaccine safety

Population-based vaccination program implementation includes monitoring of coverage, impact, and safety [8]. There are passive monitoring programs which have limitations, like incomplete reporting and coincidental associations. Because of this shortcoming, routine formal evaluations of the passive report systems are performed. There have been multiple post-licensure vaccine safety evaluations, independent of the manufacturers, both in the USA and internationally [8]. In addition, comprehensive, independent scientific reviews have been conducted to assess the safety of the HPV vaccines [25, 26].

The most common adverse events associated with HPV vaccines (as a group) reported in the literature are injection site-related: local pain, redness, and swelling. Reported systemic side effects include fatigue, fever, GI symptoms (diarrhea, nausea, vomiting), headache, myalgia, and arthralgia [19, 22, 27, 28]. Syncope is a manageable side effect of vaccination in general and simple measures can be adopted to avoid it [26]. All reported symptoms are transient and do not worsen with subsequent vaccine doses. To date, the data from clinical trials and available post-marketing periodic safety updates have indicated acceptable safety of HPV vaccines. In fact, systemic side effects did not differ between vaccinated and placebo groups for bivalent, quadrivalent, and nonavalent vaccines, and there is no increased risk of death associated with HPV vaccination [26, 29].

Data released by the Global Advisory Committee on Vaccine Safety (GACVS) in June 2017 [30] included a safety update on HPV vaccines. Since licensure in 2006, over 270 million doses of HPV vaccines have been distributed. The committee evaluated safety data for this vaccine in 2007, 2008, 2009, 2013, 2014, and 2015. Evaluation of large population-based data by the GACVS from multiple countries found no causal association between HPV vaccination and diverse symptoms that included chronic pain, motor dysfunction, complex regional pain syndrome (CRPS), or postural tachycardia syndrome (POTS) [30].

A review of reports of POTS following HPV vaccination by the Vaccine Adverse Reporting System (VAERS), commissioned by the CDC and the FDA, found approximately one POTS case for every 6.5 million worldwide distributed HPV vaccine doses (29 cases total) between 2006 and 2015. Twenty of these cases had a history of pre-existing medical conditions: chronic fatigue, asthma, and chronic headaches. For this time period, the crude reporting rate of POTS after HPV vaccination was rare, measuring 0.07% [31].

To understand the association between HPV vaccination and autonomic and/or pain disorders, a large registry-based hospital study in Finland investigated the incidence of autonomic or pain disorders for the years 2002–2012, which were prior to the introduction of the HPV vaccine in Finland. In 2002, there were two cases of POTS per 100,000 person-years, and this increased by 2012 to almost 13 cases of POTS per 100,000 person-years [32]. The investigators found that one cause for the higher annual incidence rate for POTS and chronic fatigue syndrome (CFS) was increased physician awareness of these diagnoses. It is imperative that this general increase in incidence and/or awareness of autonomic disorders is accounted for in the interpretation of data concerning any potential impact of HPV vaccination on autonomic disorders.

Dissenting opinions regarding safety

Anecdotal reports alleging possible adverse events following HPV vaccination have been published [33, 34, 35, 36, 37, 38, 39, 40]. Cited adverse events include dysautonomia, CFS, CRPS, and POTS [39].

A presumed immunological or inflammatory response to vaccination is considered the linking mechanism to the development of POTS, pain syndrome, or other form of dysautonomia [33, 34, 35, 36, 37, 38, 39, 40]. In a review of these publications, several key factors are apparent:
  1. 1.

    Some of the reported cases labeled as post HPV vaccine POTS did not have a well-defined diagnosis [37, 38], did not take into consideration effects of physical deconditioning on bedside testing [40], and clinical descriptions did not fit the accepted definition of POTS for both adolescents and children [37, 41].

  2. 2.

    Overall, the number of reported or observed POTS cases after vaccination was generally lower compared to the expected incidence that would occur naturally in the target population under almost all assumptions for all regions and countries, except for Denmark, where the majority of POTS cases that have been reported come from one syncope unit [42, 43].

  3. 3.

    Critical analysis of the Danish cohort study revealed a flawed scientific approach [43]. The Scientific Advisory Group of the European Medicines Agency investigated the Danish Syncope Unit Cohort in more detail and concluded: “this was a highly selected sample of patients, apparently chosen to fit a pre-specified hypothesis of vaccine-induced injury” [43]. All patients were referred to the same syncope unit for evaluation for an existing concern of HPV vaccine-induced illness, which makes the case series unrepresentative of the general population, and there was no control group [42]. The methods used to ascertain the trigger and time to onset of specified symptoms of autonomic dysfunction may inherently have biased patient recall [31]. There was no consistent relationship with the dose sequence to support the notion that this case series is suggestive of a specific autoimmune response to the vaccine [43].


Despite having issues in case ascertainment and classification, unsuitable analytic methods, and misleading conclusions [26], these case reports have drawn media attention to a small numbers of individuals with purported adverse reactions to HPV vaccination. The reports influence how providers communicating risks associated with not vaccinating [44, 45] are confounded by patient care-seeking behavior patterns pre- and post-vaccination [46], thus reducing the number of vaccinated individuals. In fact, the reports have created widespread fear, resulting in decreased vaccination rates or even dismantling of vaccination programs in some countries [32, 47].

It is common for a diagnosis of any syndrome or disease, including a persistent autonomic or pain disorder, to be attributed to a recent life event such as a recent illness, trauma, or even vaccination [25, 26]. The fact that certain conditions peak in incidence at the same age, and in the same population that is being vaccinated (peri-pubertal males and females), is insufficient proof of causality, especially with chronic illness such as dysautonomia and POTS, which have relapsing–remitting courses and frequent exacerbations caused by a variety of factors. Attribution of causality requires solid epidemiological data demonstrating evidence for causality at the population level, with supporting evidence of biological plausibility [48, 49].

American Autonomic Society position

At this time, the American Autonomic Society (AAS) finds that the data do not support a causal relationship between HPV vaccination and CRPS, POTS, or other forms of dysautonomia. Large population studies and exposure of over 270 million people to the HPV vaccine have not resulted in an identifiable pattern of adverse events, and no evidence of an increase in dysautonomia or POTS with use of the vaccine.

The AAS acknowledges that several groups have dissenting opinions [33, 34, 35, 36, 37, 38, 39, 40, 47]. However, the data at this time constitute only weak temporal associations between events, and their hypothesized mechanisms have not been scientifically proven. The small sample sizes, inherent selection biases, and lack of control populations preclude drawing any scientifically valid conclusions of causality [31, 42, 47].

The AAS recognizes that HPV increases the risk of cancer in patients who become infected. In the absence of compelling data for harm from vaccination, we are concerned that isolated reports linking HPV vaccination to autonomic disorders or chronic pain disorders may cause needless panic in those at risk for HPV infection and decrease the rate of HPV vaccinations. Neglecting HPV vaccination has the potential for significant public harm by eliminating equitable protection from vaccination against HPV-related cancer [26]. For example, in Japan where HPV vaccination was not proactively recommended, mortality from cervical cancer increased by 3.4% between 2005 and 2015 [44]. In contrast, herd immunity seems to develop in countries with a vaccination rate greater than 50%, with an associated decline in cancer rates [12, 50].

As with any reported autonomic disorder, the AAS supports ongoing surveillance and collection of data including the type and timing of symptom onset after vaccination, and the objectively measured severity of potential autonomic adverse effects related to HPV vaccination [23, 32, 46, 51, 52, 53, 54, 55, 56, 57]. The AAS also supports ongoing, well-designed, long-term population-based epidemiological studies that assess the safety and efficacy of vaccines of any sort. However, the AAS warns against drawing premature conclusions from poorly designed trials or small cohort studies that do not adequately assess the risks and benefits of population-level vaccination.




Compliance with ethical standards

Conflict of interest

AB—none. CHG—CHG has received research support at Beth Israel Deaconess Medical Center from Grifols Inc. CHG has served as a scientific consult for Lundbeck. CHG has served as a consultant for the United States Department of Justice (Vaccine Court). CHG has received compensation for editorial activities (Associate Editor) with Autonomic Neuroscience–basic and clinical. FA—none. EEB—none. IB—none related to this topic. IB is a consultant for and recipient of research grants from Lundbeck Pharmaceuticals and Theravance Biopharma for the development of treatments for orthostatic hypotension. MWC—none. GC—co-owner of PainStakers LLC, a company dedicated to teaching primary care physicians effective pain management. TC—co-owner of PainStakers LLC, a company dedicated to teaching primary care physicians effective pain management. WPC—none. VEC—research grants from the Heart and Stroke Foundation of Canada, Craig H Nielsen Foundation, and International Collaboration On Repair Discoveries. RF—RF received personal compensation and/or stock options for serving on scientific advisory boards of Abide, Applied Therapeutics, Astellas, Aptinyx, Biogen, Chromacel, Cutaneous NeuroDiagnostics, Ironwood, Lundbeck, MundiPharma, NeuroBo, Novartis, Pfizer, Regenacy, Spinifex, Toray and Theravance. RF received personal compensation for editorial activities (Editor) with Autonomic Neuroscience—basic and clinical. DSG—none. MJJ—none. HK—HK has served as an expert witness for the US Department of Justice in a case alleging that POTS was caused by HPV vaccination. PAL—PAL has served as an expert witness for the US Department of Justice in Vaccine Court. LNK—LNK has served as a consultant for PTC Therapeutics. DR—none. CAS—CAS received grant support from Office of Orphan Products Development. Food and Drug Administration, Grant #FD-R-04778-01-A3. CAS has received speaker honorarium from Lundbeck Pharmaceuticals. CAS received consulting honoraria from Lundbeck. CAS has received research support from the CDC, Clinical Immunization and Safety Assessment Program at Vanderbilt University Medical Center. WS—none. HS—none. SV—SV receives research support from Dysautonomia International, Genentech, Grifols, Rex Griswold Foundation, and Athena/Quest Diagnostics and personal compensation for consulting for Argenx, Alexion, and Lundbeck. SV has provided medicolegal consultation related to HPV vaccination. SRR—SRR has grant support from the Canadian Institutes of Health Research (Ottawa, Canada), Cardiac Arrhythmia Network of Canada (London, ON, Canada), and Dysautonomia International (East Moriches, NY, USA). SRR is a consultant for GE Healthcare and Lundbeck LLC, and has performed medicolegal consulting on diagnosis and causation of POTS. SRR has received compensation for editorial activities (Associate Editor) with Autonomic Neuroscience—basic and clinical.


  1. 1.
    Hamborsky J, Kroger A, Wolfe S (2015) Human papillomavirus. In: Hamborsky J, Kroger A, Wolfe S (eds) Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine preventable diseases, 13 edn. Public Health Foundation, Washington, pp 175–185Google Scholar
  2. 2.
    O’Leary ST, Campbell JD, Kimberlin DW (2018) Update from the advisory committee on immunization practices. J Pediatric Infect Dis Soc 7(4):270–274Google Scholar
  3. 3.
    Doorbar J, Egawa N, Griffin H, Kranjec C, Murakami I (2015) Human papillomavirus molecular biology and disease association. Rev Med Virol 25(Suppl 1):2–23Google Scholar
  4. 4.
    Bruni L, Diaz M, Castellsagué X, Ferrer E, Bosch FX, de Sanjosé S (2010) Cervical human papillomavirus prevalence in five continents: meta-analysis of 1 million women with normal cytological findings. J Infect Dis 202(12):1789–1799Google Scholar
  5. 5.
    Doorbar J (2016) Model systems of human papillomavirus-associated disease. J Pathol 238(2):166–179Google Scholar
  6. 6.
    Doorbar J (2018) Host control of human papillomavirus infection and disease. Best Pract Res Clin Obstet Gynaecol 47:27–41Google Scholar
  7. 7.
    Schiffman M, Castle PE, Jeronimo J, Rodriguez AC, Wacholder S (2007) Human papillomavirus and cervical cancer. Lancet 370(9590):890–907Google Scholar
  8. 8.
    Bosch FX, Broker TR, Forman D et al (2013) Comprehensive control of human papillomavirus infections and related diseases. Vaccine 31(Suppl 7):H1–H31Google Scholar
  9. 9.
    Forman D, de Martel C, Lacey CJ et al (2012) Global burden of human papillomavirus and related diseases. Vaccine 30(Suppl 5):F12–F23Google Scholar
  10. 10.
    Khode SR, Dwivedi RC, Rhys-Evans P, Kazi R (2014) Exploring the link between human papilloma virus and oral and oropharyngeal cancers. J Cancer Res Ther 10(3):492–498Google Scholar
  11. 11.
    Bryan JT, Buckland B, Hammond J, Jansen KU (2016) Prevention of cervical cancer: journey to develop the first human papillomavirus virus-like particle vaccine and the next generation vaccine. Curr Opin Chem Biol 32:34–47Google Scholar
  12. 12.
    World Health Organization (2017) Human papillomavirus vaccines: WHO position paper, May 2017-recommendations. Vaccine 35(43):5753–5755Google Scholar
  13. 13.
    Markowitz LE, Dunne EF, Saraiya M et al (2007) Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 56(RR-2):1–24Google Scholar
  14. 14.
    Centers for Disease Control and Prevention (2010) FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep 59(20):630–632Google Scholar
  15. 15.
    Centers for Disease Control and Prevention (2010) FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep 59(20):626–629Google Scholar
  16. 16.
    Dalianis T (2014) Human papillomavirus and oropharyngeal cancer, the epidemics, and significance of additional clinical biomarkers for prediction of response to therapy (Review). Int J Oncol 44(6):1799–1805Google Scholar
  17. 17.
    Jain KS, Sikora AG, Baxi SS, Morris LG (2013) Synchronous cancers in patients with head and neck cancer: risks in the era of human papillomavirus-associated oropharyngeal cancer. Cancer 119(10):1832–1837Google Scholar
  18. 18.
    Jelihovschi I, Bidescu AC, Tucaliuc SE, Iancu LS (2015) Detection of human papilloma virus in head and neck squamous cell carcinomas: a literature review. Rev Med Chir Soc Med Nat Iasi 119(2):502–509Google Scholar
  19. 19.
    Angioli R, Lopez S, Aloisi A et al (2016) Ten years of HPV vaccines: state of art and controversies. Crit Rev Oncol Hematol 102:65–72Google Scholar
  20. 20.
    Schiller JT, Castellsagué X, Garland SM (2012) A review of clinical trials of human papillomavirus prophylactic vaccines. Vaccine 30(Suppl 5):F123–F138Google Scholar
  21. 21.
    Maver PJ, Poljak M (2018) Progress in prophylactic human papillomavirus (HPV) vaccination in 2016: a literature review. Vaccine 36(36):5416–5423Google Scholar
  22. 22.
    Ackerson B, Hechter R, Sidell M et al (2017) Human papillomavirus vaccine series completion in boys before and after recommendation for routine immunization. Vaccine 35(6):897–902Google Scholar
  23. 23.
    Gee J, Weinbaum C, Sukumaran L, Markowitz LE (2016) Quadrivalent HPV vaccine safety review and safety monitoring plans for nine-valent HPV vaccine in the United States. Hum Vaccin Immunother 12(6):1406–1417Google Scholar
  24. 24.
    Hillman RJ, Giuliano AR, Palefsky JM et al (2012) Immunogenicity of the quadrivalent human papillomavirus (type 6/11/16/18) vaccine in males 16 to 26 years old. Clin Vaccine Immunol 19(2):261–267Google Scholar
  25. 25.
    Macartney KK, Chiu C, Georgousakis M, Brotherton JM (2013) Safety of human papillomavirus vaccines: a review. Drug Saf 36(6):393–412Google Scholar
  26. 26.
    Phillips A, Patel C, Pillsbury A, Brotherton J, Macartney K (2018) Safety of human papillomavirus vaccines: an updated review. Drug Saf 41(4):329–346Google Scholar
  27. 27.
    van Klooster TM, Kemmeren JM, van der Maas NA, de Melker HE (2011) Reported adverse events in girls aged 13-16 years after vaccination with the human papillomavirus (HPV)-16/18 vaccine in the Netherlands. Vaccine 29(28):4601–4607Google Scholar
  28. 28.
    Rambout L, Hopkins L, Hutton B, Fergusson D (2007) Prophylactic vaccination against human papillomavirus infection and disease in women: a systematic review of randomized controlled trials. CMAJ 177(5):469–479Google Scholar
  29. 29.
    Skufca J, Ollgren J, Artama M, Ruokokoski E, Nohynek H, Palmu AA (2018) The association of adverse events with bivalent human papilloma virus vaccination: a nationwide register-based cohort study in Finland. Vaccine 36(39):5926–5933Google Scholar
  30. 30.
    GAVS (2017) Meeting of the Global Advisory Committee on Vaccine Safety, 7–8 June 2017. Wkly Epidemiol Rec 92(28):393–402Google Scholar
  31. 31.
    Arana J, Mba-Jonas A, Jankosky C et al (2017) Reports of postural orthostatic tachycardia syndrome after human papillomavirus vaccination in the vaccine adverse event reporting system. J Adolesc Health 61(5):577–582Google Scholar
  32. 32.
    Skufca J, Ollgren J, Ruokokoski E, Lyytikäinen O, Nohynek H (2017) Incidence rates of Guillain Barré (GBS), chronic fatigue/systemic exertion intolerance disease (CFS/SEID) and postural orthostatic tachycardia syndrome (POTS) prior to introduction of human papilloma virus (HPV) vaccination among adolescent girls in Finland, 2002–2012. Papillomavirus Res 3:91–96Google Scholar
  33. 33.
    Blitshteyn S (2014) Postural tachycardia syndrome following human papillomavirus vaccination. Eur J Neurol 21(1):135–139Google Scholar
  34. 34.
    Brinth LS, Pors K, Theibel AC, Mehlsen J (2015) Orthostatic intolerance and postural tachycardia syndrome as suspected adverse effects of vaccination against human papilloma virus. Vaccine 33(22):2602–2605Google Scholar
  35. 35.
    Brinth LS, Mehlsen J (2016) Response to letter to the editor. Vaccine 34(38):4469Google Scholar
  36. 36.
    Martínez-Lavín M (2015) Hypothesis: human papillomavirus vaccination syndrome–small fiber neuropathy and dysautonomia could be its underlying pathogenesis. Clin Rheumatol 34(7):1165–1169Google Scholar
  37. 37.
    Hendrickson JE, Hendrickson ET, Gehrie EA et al (2016) Complex regional pain syndrome and dysautonomia in a 14-year-old girl responsive to therapeutic plasma exchange. J Clin Apher 31(4):368–374Google Scholar
  38. 38.
    Takahashi Y, Matsudaira T, Nakano H et al (2016) Immunological studies of cerebrospinal fluid from patients with CNS symptoms after human papillomavirus vaccination. J Neuroimmunol 298:71–78Google Scholar
  39. 39.
    Baker B, Eça Guimarães L, Tomljenovic L, Agmon-Levin N, Shoenfeld Y (2015) The safety of human papilloma virus-blockers and the risk of triggering autoimmune diseases. Expert Opin Drug Saf 14(9):1387–1394Google Scholar
  40. 40.
    Tomljenovic L, Colafrancesco S, Perricone C, Shoenfeld Y (2014) Postural orthostatic tachycardia with chronic fatigue after HPV vaccination as part of the “autoimmune/auto-inflammatory syndrome induced by adjuvants”: case report and literature review. J Investig Med High Impact Case Rep 2(1):2324709614527812Google Scholar
  41. 41.
    Freeman R, Wieling W, Axelrod FB et al (2011) Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res 21(2):69–72Google Scholar
  42. 42.
    Butts BN, Fischer PR, Mack KJ (2017) Human papillomavirus vaccine and postural orthostatic tachycardia syndrome: a review of current literature. J Child Neurol 32(11):956–965Google Scholar
  43. 43.
    Pharmacovigilance Risk Assessment Committee EMA (2015) Assessment report. Review under Article 20 of Regulation (EC) No. 726/2004. Human papillomavirus (HPV) vaccines. London, EMA. Accessed May 2018
  44. 44.
    Iwata S, Okada K, Kawana K, Expert Council on Promotion of Vaccination (2017) Consensus statement from 17 relevant Japanese academic societies on the promotion of the human papillomavirus vaccine. Vaccine 35(18):2291–2292Google Scholar
  45. 45.
    Dixon GN (2017) Making vaccine messaging stick: perceived causal instability as a barrier to effective vaccine messaging. J Health Commun 22(8):631–637Google Scholar
  46. 46.
    Mølbak K, Hansen ND, Valentiner-Branth P (2016) Pre-vaccination care-seeking in females reporting severe adverse reactions to HPV vaccine A registry based case-control study. PLoS One 11(9):e0162520Google Scholar
  47. 47.
  48. 48.
    Tafuri S, Fortunato F, Gallone MS et al (2018) Systematic causality assessment of adverse events following HPV vaccines: analysis of current data from Apulia region (Italy). Vaccine 36(8):1072–1077Google Scholar
  49. 49.
    Works Health Organization (2018) Causality assessment of an adverse event following immunization (AEFI): user manual for the revised WHO classification. WHO, Geneva. Accessed Dec 2018Google Scholar
  50. 50.
    Drolet M, Bénard É, Boily MC et al (2015) Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis 15(5):565–580Google Scholar
  51. 51.
    Cameron RL, Ahmed S, Pollock KG (2016) Adverse event monitoring of the human papillomavirus vaccines in Scotland. Intern Med J 46(4):452–457Google Scholar
  52. 52.
    Petousis-Harris H (2016) Proposed HPV vaccination syndrome is unsubstantiated. Clin Rheumatol 35(3):833–834Google Scholar
  53. 53.
    Andrews N, Stowe J, Miller E (2017) No increased risk of Guillain-Barré syndrome after human papilloma virus vaccine: a self-controlled case-series study in England. Vaccine 35(13):1729–1732Google Scholar
  54. 54.
    Donegan K, Beau-Lejdstrom R, King B, Seabroke S, Thomson A, Bryan P (2013) Bivalent human papillomavirus vaccine and the risk of fatigue syndromes in girls in the UK. Vaccine 31(43):4961–4967Google Scholar
  55. 55.
    Miranda S, Chaignot C, Collin C, Dray-Spira R, Weill A, Zureik M (2017) Human papillomavirus vaccination and risk of autoimmune diseases: a large cohort study of over 2 million young girls in France. Vaccine 35(36):4761–4768Google Scholar
  56. 56.
    Grimaldi-Bensouda L, Rossignol M, Koné-Paut I et al (2017) Risk of autoimmune diseases and human papilloma virus (HPV) vaccines: six years of case-referent surveillance. J Autoimmun 79:84–90Google Scholar
  57. 57.
    Liu EY, Smith LM, Ellis AK et al (2018) Quadrivalent human papillomavirus vaccination in girls and the risk of autoimmune disorders: the Ontario Grade 8 HPV vaccine cohort study. CMAJ 190(21):E648–E655Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Alexandru Barboi
    • 1
    • 17
    Email author
  • Christopher H. Gibbons
    • 2
  • Felicia Axelrod
    • 3
  • Eduardo E. Benarroch
    • 4
  • Italo Biaggioni
    • 5
  • Mark W. Chapleau
    • 6
  • Gisela Chelimsky
    • 7
  • Thomas Chelimsky
    • 8
  • William P. Cheshire
    • 9
  • Victoria E. Claydon
    • 10
  • Roy Freeman
    • 2
  • David S. Goldstein
    • 11
  • Michael J. Joyner
    • 12
  • Horacio Kaufmann
    • 3
  • Phillip A. Low
    • 4
  • Lucy Norcliffe-Kaufmann
    • 13
  • David Robertson
    • 5
  • Cyndya A. Shibao
    • 5
  • Wolfgang Singer
    • 4
  • Howard Snapper
    • 14
  • Steven Vernino
    • 15
  • Satish R. Raj
    • 5
    • 16
  • on behalf of the American Autonomic Society
  1. 1.Department of Neurology, NorthShore University Health System, Pritzker School of MedicineUniversity of ChicagoChicagoUSA
  2. 2.Department of Neurology, Beth Israel Deaconess Medical CenterHarvard UniversityBostonUSA
  3. 3.Departments of NeurologyNew York UniversityNew YorkUSA
  4. 4.Department of NeurologyMayo ClinicRochesterUSA
  5. 5.Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction CenterVanderbilt University School of MedicineNashvilleUSA
  6. 6.Departments of Medicine and Molecular Physiology and BiophysicsUniversity of IowaIowa CityUSA
  7. 7.Department of PediatricsMedical College of WisconsinMilwaukeeUSA
  8. 8.Department of NeurologyMedical College of WisconsinMilwaukeeUSA
  9. 9.Department of NeurologyMayo ClinicJacksonvilleUSA
  10. 10.Department of Biomedical Physiology and KinesiologySimon Fraser UniversityBurnabyCanada
  11. 11.Autonomic Medicine SectionNational Institute of Neurological, Diseases and Stroke, National Institutes of HealthBethesdaUSA
  12. 12.Department of Anesthesia and Perioperative MedicineMayo ClinicRochesterUSA
  13. 13.Departments of Physiology and NeurosciencesNew York UniversityNew YorkUSA
  14. 14.Cardiology DivisionWellstar Healthcare SystemAtlantaUSA
  15. 15.Department of Neurology and NeurotherapeuticsUT Southwestern Medical CenterDallasUSA
  16. 16.Department of Cardiac Sciences, Libin Cardiovascular Institute of AlbertaUniversity of CalgaryCalgaryCanada
  17. 17.American Autonomic SocietyLa JollaUSA

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