Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Brain. 2013 Aug;136(Pt 8):2486-96. doi: 10.1093/brain/awt187.
Increased risk of narcolepsy in children and adults after pandemic H1N1 vaccination in France.
Dauvilliers Y, Arnulf I, Lecendreux M, Monaca Charley C, Franco P, Drouot X, d'Ortho MP, Launois S, Lignot S, Bourgin P, Nogues B, Rey M, Bayard S, Scholz S, Lavault S, Tubert-Bitter P, Saussier C, Pariente A; Narcoflu-VF study group.
Source

1 Sleep Disorder Centre, Neurology Department, Gui de Chauliac hospital, CHU Montpellier, INSERM, U1061, Montpellier, France.
Abstract

An increased incidence of narcolepsy in children was detected in Scandinavian countries where pandemic H1N1 influenza ASO3-adjuvanted vaccine was used. A campaign of vaccination against pandemic H1N1 influenza was implemented in France using both ASO3-adjuvanted and non-adjuvanted vaccines. As part of a study considering all-type narcolepsy, we investigated the association between H1N1 vaccination and narcolepsy with cataplexy in children and adults compared with matched controls; and compared the phenotype of narcolepsy with cataplexy according to exposure to the H1N1 vaccination. Patients with narcolepsy-cataplexy were included from 14 expert centres in France. Date of diagnosis constituted the index date. Validation of cases was performed by independent experts using the Brighton collaboration criteria. Up to four controls were individually matched to cases according to age, gender and geographic location. A structured telephone interview was performed to collect information on medical history, past infections and vaccinations. Eighty-five cases with narcolepsy-cataplexy were included; 23 being further excluded regarding eligibility criteria. Of the 62 eligible cases, 59 (64% males, 57.6% children) could be matched with 135 control subjects. H1N1 vaccination was associated with narcolepsy-cataplexy with an odds ratio of 6.5 (2.1-19.9) in subjects aged <18 years, and 4.7 (1.6-13.9) in those aged 18 and over. Sensitivity analyses considering date of referral for diagnosis or the date of onset of symptoms as the index date gave similar results, as did analyses focusing only on exposure to ASO3-adjuvanted vaccine. Slight differences were found when comparing cases with narcolepsy-cataplexy exposed to H1N1 vaccination (n = 32; mostly AS03-adjuvanted vaccine, n = 28) to non-exposed cases (n = 30), including shorter delay of diagnosis and a higher number of sleep onset rapid eye movement periods for exposed cases. No difference was found regarding history of infections. In this sub-analysis, H1N1 vaccination was strongly associated with an increased risk of narcolepsy-cataplexy in both children and adults in France. Even if, as in every observational study, the possibility that some biases participated in the association cannot be completely ruled out, the associations appeared robust to sensitivity analyses, and a specific analysis focusing on ASO3-adjuvanted vaccine found similar increase.
KEYWORDS:

H1N1, cataplexy, infection, narcolepsy, vaccine

PMID:
23884811
[PubMed - in process]

http://www.ncbi.nlm.nih.gov/pubmed/23884811

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Citation: Mel?n K, Partinen M, Tynell J, Sillanp?? M, Himanen S-L, et al. (2013) No Serological Evidence of Influenza A H1N1pdm09 Virus Infection as a Contributing Factor in Childhood Narcolepsy after Pandemrix Vaccination Campaign in Finland. PLoS ONE 8(8): e68402. doi:10.1371/journal.pone.0068402


Abstract
Background

Narcolepsy cataplexy syndrome, characterised by excessive daytime sleepiness and cataplexy, is strongly associated with a genetic marker, human leukocyte antigen (HLA) DQB1*06:02. A sudden increase in the incidence of childhood narcolepsy was observed after vaccination with AS03-adjuvanted Pandemrix influenza vaccine in Finland at the beginning of 2010. Here, we analysed whether the coinciding influenza A H1N1pdm pandemic contributed, together with the Pandemrix vaccination, to the increased incidence of childhood narcolepsy in 2010. The analysis was based on the presence or absence of antibody response against non-structural protein 1 (NS1) from H1N1pdm09 virus, which was not a component of Pandemrix vaccine.
Methods

Non-structural (NS) 1 proteins from recombinant influenza A/Udorn/72 (H3N2) and influenza A/Finland/554/09 (H1N1pdm09) viruses were purified and used in Western blot analysis to determine specific antibody responses in human sera. The sera were obtained from 45 patients who fell ill with narcolepsy after vaccination with AS03-adjuvanted Pandemrix at the end of 2009, and from controls.
Findings

Based on quantitative Western blot analysis, only two of the 45 (4.4%) Pandemrix-vaccinated narcoleptic patients showed specific antibody response against the NS1 protein from the H1N1pdm09 virus, indicating past infection with the H1N1pdm09 virus. Instead, paired serum samples from patients, who suffered from a laboratory confirmed H1N1pdm09 infection, showed high levels or diagnostic rises (96%) in H1N1pdm virus NS1-specific antibodies and very high cross-reactivity to H3N2 subtype influenza A virus NS1 protein.
Conclusion

Based on our findings, it is unlikely that H1N1pdm09 virus infection contributed to a sudden increase in the incidence of childhood narcolepsy observed in Finland in 2010 after AS03-adjuvanted Pandemrix vaccination.

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0068402

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Influenza vaccine H1N1: the French case of narcolepsy-cataplexy confirmed

Montpellier, France-The results of a sub-analysis of the case-control study NarcoFlu-VF confirm the link between mass vaccination against the influenza A (H1N1) which took place in late 2009 in France and several cases of narcolepsy-cataplexy (1)).

Just a year ago, The national security agency in the medication (ANSM) reported the results of two studies on the subject: the European study VAESCO (Vaccine Adverse Event Surveillance * Communication) and preliminary data from the study NarcoFlu-VF, conducted in France only (2)).

The French data of the study VAESCO highlighted an increase in the risk of narcolepsy in adults. And, those of the study NarcoFlu-VF, a significant association both for adults and for children and adolescents.


The results of a new sub-analysis of the study NarcoFlu-VF confirm this association, with an increased risk of narcolepsy with cataplexy.




The results are published in the journal Brain of the month of August.


..

http://www.medscape.fr/infections-vaccins/articles/1583477/

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Is narcolepsy linked to an H1N1 vaccine?

Children around the world are developing severe narcolepsy ? a rare and incurable sleep disorder ? in troubling numbers, with researchers working on a theory that some cases may be linked to the H1N1 virus, others perhaps to an H1N1 vaccine.

Narcolepsy normally affects only 1 in 2,000, and is rare in young children. But doctors across Europe and China have reported spikes in cases among patients since the H1N1 pandemic outbreak in 2009.

Now, a W5 investigation has found experts in Canada, too, may be seeing a rise in cases among children and are probing a possible link to the vaccine used during the 2009 pandemic.

Researchers in Quebec have reported a four times increased risk of narcolepsy after patients received the pandemic flu vaccine Arepanrix (called Pandemrix outside Canada), compared to those who did not receive it, although the risk is considered remote and they suggest the H1N1 virus itself may be responsible for some of the increased cases.

...

http://www.thestar.com/news/canada/2013/11/02/is_narcolepsy_linked_to_an_h1n1_vaccine.html

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

H1N1-triggered narcolepsy may stem from 'molecular mimicry,' study finds


The study provides some of the most compelling cellular and molecular evidence to date for a scientific concept known as "molecular mimicry." Mimicry is the idea that the normal immune response to a pathogen, in this case the pandemic 2009 H1N1 influenza virus, can trigger autoimmunity - when the immune system mistakenly attacks healthy components of the body - because of similarity between a pathogen protein and a human protein.

In a 2009 study, Stanford researchers reported genetic evidence supporting the idea that narcolepsy, a debilitating disorder characterized by sudden, uncontrollable sleepiness and muscle weakness, occurs because the body's immune system mistakenly destroys brain cells that make a "wakefulness" protein: hypocretin. The new study confirms that narcolepsy is an autoimmune disease.

"The relationship between H1N1 infection, vaccination and narcolepsy gave us some very interesting insight into possible causes of the condition," said Emmanuel Mignot, MD, PhD, professor of psychiatry and behavioral sciences. "In particular, it strongly suggested to us that T cells of the immune system primed to attack H1N1 can occasionally also cross-react with hypocretin and somehow cause the destruction of hypocretin-producing neurons."


- See more at: http://www.noodls.com/view/68A41EC8D....pdZsuL4J.dpuf

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

The original article

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Giuseppe Michieli

The Lancet Infectious Diseases, Early Online Publication, 19 December 2013
doi:10.1016/S1473-3099(13)70238-XCite or Link Using DOI
This article can be found in the following collections: Public Health; Infectious Diseases (Immunisation & vaccination)
Copyright ? 2013 Elsevier Ltd All rights reserved.
Pandemic influenza A H1N1 vaccines and narcolepsy: vaccine safety surveillance in action
Dr Charlotte I S Barker BMBCh a b Corresponding AuthorEmail Address, Matthew D Snape MD a c
Summary
The 2009 influenza A H1N1 pandemic placed unprecedented demand on public health authorities and the vaccine industry. Efforts were coordinated internationally to maximise the speed of vaccine development, distribution, and delivery, and the European Union's novel fast-track authorisation procedures mandated increased postmarketing surveillance to monitor vaccine safety. Clinicians in Finland and Sweden later identified an apparent increase in the incidence of narcolepsy associated with a specific adjuvanted pandemic influenza vaccine. After extensive review, the European Medicines Agency confirmed the existence of this association, which has since been detected in England, Ireland, France, and Norway. Assessments of the causal mechanisms continue. In this Review, we discuss how the narcolepsy association was detected, and we present the evidence according to the causality assessment criteria for adverse events following immunisation. The lessons learnt emphasise the central role of alert clinicians in reporting of suspected adverse reactions, and the importance of internationally robust postmarketing surveillance strategies as crucial components in future mass immunisation programmes.

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2813%2970238-X/abstract?rss=yes

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Key narcolepsy?influenza vaccine findings retracted

Since swine flu swept the globe in 2009, scientists have scrambled to determine why a small percentage of children in Europe who received the flu vaccine Pandemrix developed narcolepsy, an incurable brain disorder that causes irresistible sleepiness. This week, a promising explanation was dealt a setback when prominent sleep scientist Emmanuel Mignot of Stanford University in Palo Alto, California, and colleagues retracted their influential study reporting a potential link between the H1N1 virus used to make the vaccine and narcolepsy.

Some researchers were taken aback. ?This was one of the most important pieces of work on narcolepsy that has come out,? says neuroimmunologist Lawrence Steinman, a close friend and colleague of Mignot?s, who is also at Stanford. The retraction, announced in Science Translational Medicine (STM), ?really caught me by surprise,? he says. Others say that journal editors should have detected problems with the study?s methodology.


...

http://news.sciencemag.org/brain-behavior/2014/07/key-narcolepsy-influenza-vaccine-findings-retracted

[Emily]

Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

http://retractionwatch.com/2014/07/3...mmune-disease/

Retraction Watch

Tracking retractions as a window into the scientific process
Authors retract paper ?confirming? that narcolepsy is an autoimmune disease

...
We asked the paper?s corresponding authors, Stanford?s Emmanuel Mignot and Elizabeth Mellins, how the issues with the findings came to light. Mignot tells us:

"We were just continuing our work based on the finding, trying to establish it as a diagnostic test, but could not replicate it. No other work is affected, and in fact the DQ binding studies of that article are perfectly fine. Only the [Enzyme-Linked ImmunoSpot (ELISPOT)] results are in question."..

Sciencemag reports the autoimmunity hypothesis is still viable:

Like Mignot and many other researchers, Vaarala still believes that some part of the influenza virus used to make Pandemrix likely mimics a native protein in the brain and triggered an autoimmune reaction that led to the destruction of hypocretin neurons in susceptible children. She is now looking for differences between Pandemrix and other flu vaccines and says she has already identified another promising protein candidate.

Hopefully the research will eventually hone in on a method to screen for and avoid serious flu vaccine side effects.

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Re: Finland - National Health Dept. Suspends A/H1N1 Vaccine Due to Possible Narcolepsy Connection + other countries investigate

Eurosurveillance, Volume 19, Issue 36, 11 September 2014
Surveillance and outbreak reports
Did narcolepsy occur following administration of AS03-adjuvanted A(H1N1) pandemic vaccine in Ontario, Canada? A review of post-marketing safety surveillance data
T Harris ()1, K Wong1, L Stanford2, J Fediurek1, N Crowcroft1,3,4, S L Deeks1,3

Public Health Ontario, Toronto, Ontario, Canada
Simcoe-Muskoka District Health Unit, Ontario, Canada
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada

Citation style for this article: Harris T, Wong K, Stanford L, Fediurek J, Crowcroft N, Deeks SL. Did narcolepsy occur following administration of AS03-adjuvanted A(H1N1) pandemic vaccine in Ontario, Canada? A review of post-marketing safety surveillance data . Euro Surveill. 2014;19(36):pii=20900. Available online: http://www.eurosurveillance.org/View...rticleId=20900
Date of submission: 09 October 2013

A vaccine safety signal and association between new onset of narcolepsy and AS03-adjuvanted pandemic influenza A(H1N1) vaccine (Pandemrix, GlaxoSmithKline) in children and young adults has been reported in several European countries. In Ontario, Canada, AS03-adjuvanted pandemic A(H1N1) vaccine (Arepanrix, GlaxoSmithKline) was the primary vaccine administered in 2009/10, with 4.8 million doses distributed. We assessed post-marketing safety surveillance data by extracting adverse events following immunisation (AEFIs) associated with this vaccine from the integrated Public Health Information System. Reports were screened for key terms related to narcolepsy and further limited to children and young adults four to 29 years of age. Of 1,604 AEFIs reported in Ontario, 53 reports met the search criteria. Individual assessment by a nurse consultant for additional context suggestive of narcolepsy yielded five reports for secondary medical review. None of the five reports proved consistent with a possible narcolepsy diagnosis based on the available information. We present the first post-marketing assessment from Canada of narcolepsy reports following receipt of Arepanix. Continued investigation of differences between Arepanrix and Pandemrix and subsequent risk of narcolepsy is indicated. In light of the limitations of passive surveillance to detect a signal in this instance, validation using other data sources is prudent.

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20900

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H1N1 Viral Proteins Could Be Link Between Pandemrix and Narcolepsy

Though much of the research for a link between Pandemrix and narcolepsy has focused on the flu vaccine?s adjuvant, a new study suggests the focus should actually be on the H1N1 viral proteins.
In their paper, ?Antigenic Differences between AS03 Adjuvanted Influenza A (H1N1) Pandemic Vaccines: Implications for Pandemrix-Associated Narcolepsy Risk? published in PLOS One on December 15, Finnish researchers compare two different versions of the H1N1 flu vaccine-Pandemrix and Arepanrix-and find an interesting difference.
?What is more significant is that given that there were two pandemic vaccines against swine flu?one was Arepanrix, which was used in Canada, and the other was Pandemrix, which was used in Europe?Pandemrix caused narcolepsy,? first author Outi Vaarala told Finnish media outlet Yle. ?The difference was that Pandemrix had one viral protein in a different form and there was more of it.?

...

http://www.sleepreviewmag.com/2014/12/h1n1-viral-proteins-link-pandemrix-narcolepsy/

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J Intern Med. 2015 Feb 14. doi: 10.1111/joim.12355. [Epub ahead of print]
Increased β-haemolytic group A streptococcal M6 serotype and streptodornase B-specific cellular immune responses in Swedish narcolepsy cases.

Ambati A¹, Poiret T, Svahn BM, Valentini D, Khademi M, Kockum I, Lima I, Arnheim-Dahlstr?m L, Lamb F, Fink K, Meng Q, Kumar A, Rane L, Olsson T, Maeurer M.
Author information

Abstract

BACKGROUND:

Type 1 narcolepsy is a neurological disorder characterized by excessive daytime sleepiness and cataplexy associated with the HLA allele DQB1*06:02. Genetic predisposition along with external triggering factors may drive autoimmune responses, ultimately leading to the selective loss of hypocretin-positive neurons.
OBJECTIVE:

The aim of this study was to investigate potential aetiological factors in Swedish cases of post-vaccination (Pandemrix) narcolepsy defined by interferon-gamma (IFNγ) production from immune cells in response to molecularly defined targets.
METHODS:

Cellular reactivity defined by IFNγ production was examined in blood from 38 (HLA-DQB1*06:02⁺ ) Pandemrix-vaccinated narcolepsy cases and 76 (23 HLA-DQB1*06:02⁺ and 53 HLA-DQB1*06:02^- ) control subjects, matched for age, sex and exposure, using a variety of different antigens: β-haemolytic group A streptococcal (GAS) antigens (M5, M6 and streptodornase B), influenza (the pandemic A/H1N1/California/7/09 NYMC X-179A and A/H1N1/California/7/09 NYMC X-181 vaccine antigens, previous Flu-A and -B vaccine targets, A/H1N1/Brisbane/59/2007, A/H1N1/Solomon Islands/3/2006, A/H3N2/Uruguay/716/2007, A/H3N2/Wisconsin/67/2005, A/H5N1/Vietnam/1203/2004 and B/Malaysia/2506/2004), non-influenza viral targets (CMVpp65, EBNA-1 and EBNA-3) and auto-antigens (hypocretin peptide, Tribbles homolog 2 peptide cocktail and extract from rat hypothalamus tissue).
RESULTS:

IFNγ production was significantly increased in whole blood from narcolepsy cases in response to streptococcus serotype M6 (P = 0.0065) and streptodornase B protein (P = 0.0050). T cell recognition of M6 and streptodornase B was confirmed at the single-cell level by intracellular cytokine (IL-2, IFNγ, tumour necrosis factor-alpha and IL-17) production after stimulation with synthetic M6 or streptodornase B peptides. Significantly higher (P = 0.02) titres of serum anti-streptolysin O were observed in narcolepsy cases, compared to vaccinated controls.
CONCLUSION:

β-haemolytic GAS may be involved in triggering autoimmune responses in patients who developed narcolepsy symptoms after vaccination with Pandemrix in Sweden, characterized by a Streptococcus pyogenes M-type-specific IFNγ cellular immune response. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.


KEYWORDS:

Streptococcus ; Pandemrix; Streptolysin; T cells; interferon-gamma; narcolepsy

PMID: 25683265 [PubMed - as supplied by publisher]

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Flu Vaccine and Narcolepsy: New Findings May Explain Link

An unusual increase in narcolepsy cases in Europe was linked to a new flu vaccine used there, and now researchers may have figured out why: A protein in the vaccine appears to mimic one in the brain that plays a role in the sleep disorder.
People with narcolepsy experience severe daytime sleepiness and "sleep attacks," in which they suddenly fall asleep for a short time. The vaccine that was linked to the disorder was used in 2009 and 2010 to protect against the H1N1 strain of flu, which is sometimes called the swine flu.
The new findings also suggest that the immune system may play a role in the disorder, and that in rare cases vaccines or infections can trigger narcolepsy in people with a certain genetic mutation.

...

Flu Vaccine and Narcolepsy: New Findings May Explain Link

by Rachael Rettner, Senior Writer | July 01, 2015 02:05pm ET

Credit: Syda Productions/Shutterstock.com View full size image

An unusual increase in narcolepsy cases in Europe was linked to a new flu vaccine used there, and now researchers may have figured out why: A protein in the vaccine appears to mimic one in the brain that plays a role in the sleep disorder.
People with narcolepsy experience severe daytime sleepiness and "sleep attacks," in which they suddenly fall asleep for a short time. The vaccine that was linked to the disorder was used in 2009 and 2010 to protect against the H1N1 strain of flu, which is sometimes called the swine flu.
The new findings also suggest that the immune system may play a role in the disorder, and that in rare cases vaccines or infections can trigger narcolepsy in people with a certain genetic mutation.



In the new study, the researchers compared components of the Pandemrix vaccine with those of another H1N1 vaccine, called Focetria, which was manufactured by Novartis.
They found that part of a viral protein in the Pandemrix vaccine mimicked the structure of a brain receptor that binds to a hormone called hypocretin. This hormone is involved in keeping people awake, and people with narcolepsy have lower levels of hypocretin, which led the researchers to hypothesize that problems with hypocretin or its receptor could play a role in the sleep disorder.
In contrast to the Pandemrix vaccine, the Focetria vaccine contained much lower levels of the viral protein that mimicked the hypocretin receptor.
Next, the researchers analyzed blood samples from 20 people in Finland who developed narcolepsy after Pandemrix vaccination, and found that these people had antibodies in their blood that bound to the H1N1 virus and also to the hypocretin receptor. But people who received the Focetria vaccines did not have these antibodies.
The researchers speculate that, in people who are already predisposed to narcolepsy because of a genetic mutation, receiving the Pandemrix vaccination triggered an autoimmune response ? these patients developed antibodies that not only attacked the virus, but also attacked the hypocretin receptor in the brain.

http://www.livescience.com/51411-flu-vaccine-narcolepsy-immune-response.html

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The oiginal article

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J Intern Med. 2015 Jun 30. doi: 10.1111/joim.12391. [Epub ahead of print]
A coordinated cross-disciplinary research initiative to address an increased incidence of narcolepsy following the 2009-2010 Pandemrix vaccination programme in Sweden.

Feltelius N¹, Persson I¹, Ahlqvist-Rastad J¹, Andersson M¹, Arnheim-Dahlstr?m L², Bergman P³, Granath F⁴, Adori C⁵, H?kfelt T⁵, K?hlmann-Berenzon S⁶, Liljestr?m P⁷, Maeurer M⁸, Olsson T⁹, ?rtqvist ?^10,11, Partinen M^12,13, Salmonson T¹, Zethelius B¹.
Author information

Abstract

In response to the 2009-2010 influenza A(H1N1)pdm09 pandemic, a mass vaccination programme with the AS03-adjuvanted influenza A(H1N1) vaccine Pandemrix was initiated in Sweden. Unexpectedly, there were a number of narcolepsy cases amongst vaccinated children and adolescents reported. In this review, we summarize the results of a joint cross-disciplinary national research effort to investigate the adverse reaction signal from the spontaneous reporting system and to better understand possible causative mechanisms. A three- to fourfold increased risk of narcolepsy in vaccinated children and adolescents was verified by epidemiological studies. Of importance, no risk increase was observed for the other neurological and autoimmune diseases studied. Genetic studies confirmed the association with the allele HLA-DQB1*06:02, which is known to be related to sporadic narcolepsy. Furthermore, a number of studies using cellular and molecular experimental models investigated possible links between influenza vaccination and narcolepsy. Serum analysis, using a peptide microarray platform, showed that individuals who received Pandemrix exhibited a different epitope reactivity pattern to neuraminidase and haemagglutinin, as compared to individuals who were infected with H1N1. Patients with narcolepsy were also found to have increased levels of interferon-gamma production in response to streptococcus-associated antigens. The chain of patient-related events and the study results emerging over time were subjected to intense nationwide media attention. The importance of transparent communication and collaboration with patient representatives to maintain public trust in vaccination programmes is also discussed in the review. Organizational challenges due to this unexpected event delayed the initiation of some of the research projects, still the main objectives of this joint, cross-disciplinary research effort were reached, and important insights were acquired for future, similar situations in which a fast and effective task force may be required to evaluate vaccination-related adverse events.
? 2015 The Association for the Publication of the Journal of Internal Medicine.


KEYWORDS:

Sweden; adverse events; influenza; narcolepsy; vaccination

PMID: 26123389 [PubMed - as supplied by publisher]