Abstract
Introduction
Human papillomavirus (HPV) vaccination has been anecdotally connected to the development of dysautonomia, chronic fatigue, complex regional pain syndrome and postural tachycardia syndrome.
Objectives
To critically evaluate a potential connection between HPV vaccination and the above-noted conditions.
Methods
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.
Results
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.
Conclusion
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.
Similar content being viewed by others
References
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 175–185
O’Leary ST, Campbell JD, Kimberlin DW (2018) Update from the advisory committee on immunization practices. J Pediatric Infect Dis Soc 7(4):270–274
Doorbar J, Egawa N, Griffin H, Kranjec C, Murakami I (2015) Human papillomavirus molecular biology and disease association. Rev Med Virol 25(Suppl 1):2–23
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):1789–1799
Doorbar J (2016) Model systems of human papillomavirus-associated disease. J Pathol 238(2):166–179
Doorbar J (2018) Host control of human papillomavirus infection and disease. Best Pract Res Clin Obstet Gynaecol 47:27–41
Schiffman M, Castle PE, Jeronimo J, Rodriguez AC, Wacholder S (2007) Human papillomavirus and cervical cancer. Lancet 370(9590):890–907
Bosch FX, Broker TR, Forman D et al (2013) Comprehensive control of human papillomavirus infections and related diseases. Vaccine 31(Suppl 7):H1–H31
Forman D, de Martel C, Lacey CJ et al (2012) Global burden of human papillomavirus and related diseases. Vaccine 30(Suppl 5):F12–F23
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):492–498
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 32:34–47
World Health Organization (2017) Human papillomavirus vaccines: WHO position paper, May 2017-recommendations. Vaccine 35(43):5753–5755
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):1–24
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):630–632
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):626–629
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):1799–1805
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):1832–1837
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):502–509
Angioli R, Lopez S, Aloisi A et al (2016) Ten years of HPV vaccines: state of art and controversies. Crit Rev Oncol Hematol 102:65–72
Schiller JT, Castellsagué X, Garland SM (2012) A review of clinical trials of human papillomavirus prophylactic vaccines. Vaccine 30(Suppl 5):F123–F138
Maver PJ, Poljak M (2018) Progress in prophylactic human papillomavirus (HPV) vaccination in 2016: a literature review. Vaccine 36(36):5416–5423
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):897–902
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):1406–1417
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):261–267
Macartney KK, Chiu C, Georgousakis M, Brotherton JM (2013) Safety of human papillomavirus vaccines: a review. Drug Saf 36(6):393–412
Phillips A, Patel C, Pillsbury A, Brotherton J, Macartney K (2018) Safety of human papillomavirus vaccines: an updated review. Drug Saf 41(4):329–346
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):4601–4607
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):469–479
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):5926–5933
GAVS (2017) Meeting of the Global Advisory Committee on Vaccine Safety, 7–8 June 2017. Wkly Epidemiol Rec 92(28):393–402
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):577–582
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 3:91–96
Blitshteyn S (2014) Postural tachycardia syndrome following human papillomavirus vaccination. Eur J Neurol 21(1):135–139
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):2602–2605
Brinth LS, Mehlsen J (2016) Response to letter to the editor. Vaccine 34(38):4469
Martínez-Lavín M (2015) Hypothesis: human papillomavirus vaccination syndrome–small fiber neuropathy and dysautonomia could be its underlying pathogenesis. Clin Rheumatol 34(7):1165–1169
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):368–374
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 298:71–78
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):1387–1394
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):2324709614527812
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):69–72
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):956–965
Pharmacovigilance Risk Assessment Committee EMA (2015) Assessment report. Review under Article 20 of Regulation (EC) No. 726/2004. Human papillomavirus (HPV) vaccines. London, EMA. http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/HPV_vaccines_20/Opinion_provided_by_Committee_for_Medicinal_Products_for_Human_Use/WC500197129.pdf. Accessed May 2018
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):2291–2292
Dixon GN (2017) Making vaccine messaging stick: perceived causal instability as a barrier to effective vaccine messaging. J Health Commun 22(8):631–637
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):e0162520
Joelving F (2017) What the Gardasil testing may have missed. https://slate.com/health-and-science/2017/12/flaws-in-the-clinical-trials-for-gardasil-made-it-harderto-properly-assess-safety.html. Accessed Jan 2018
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):1072–1077
Works Health Organization (2018) Causality assessment of an adverse event following immunization (AEFI): user manual for the revised WHO classification. WHO, Geneva. Accessed Dec 2018
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):565–580
Cameron RL, Ahmed S, Pollock KG (2016) Adverse event monitoring of the human papillomavirus vaccines in Scotland. Intern Med J 46(4):452–457
Petousis-Harris H (2016) Proposed HPV vaccination syndrome is unsubstantiated. Clin Rheumatol 35(3):833–834
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):1729–1732
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):4961–4967
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):4761–4768
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 79:84–90
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–E655
Funding
None.
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
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.
Additional information
This article is co-published in the journals “Clinical Autonomic Research” and “Autonomic Neuroscience”. https://doi.org/10.1007/s10286-019-00608-w or https://doi.org/10.1016/j.autneu.2019.05.002.
These articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style.
Rights and permissions
About this article
Cite this article
Barboi, A., Gibbons, C.H., Axelrod, F. et al. Human papillomavirus (HPV) vaccine and autonomic disorders: a position statement from the American Autonomic Society. Clin Auton Res 30, 13–18 (2020). https://doi.org/10.1007/s10286-019-00608-w
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10286-019-00608-w