Conclusion
Natural infection with respiratory syncytial virus (RSV) in infancy can increase the risk of asthma in childhood, as well as contribute to asthma exacerbation. Other respiratory viruses such as influenza can also contribute to asthma exacerbation. Thus, RSV vaccine prevents asthma and asthma exacerbation, and influenza vaccine prevents asthma exacerbation, by protecting against natural infection. Influenza vaccines do not cause asthma or asthma exacerbation. MMR vaccines do not cause and may protect against asthma. Other vaccines currently routinely recommended to the general population in the U.S.* have not been shown to cause asthma or asthma exacerbation. Aluminum adjuvants in vaccines have not been shown to cause asthma in children.
Epidemiological evidence
The 2012 report on adverse effects of vaccines by the Institute of Medicine (IOM) 1, now called the National Academy of Medicine (NAM), described a number of studies with sufficient validity and precision that all found no association between inactivated influenza vaccination and asthma exacerbation 2-10. The report described several studies with sufficient validity and precision that generally reported no association between live attenuated influenza vaccination (LAIV) and asthma exacerbation as well 11-17.
A 2015 white paper on the safety of influenza vaccines concluded that LAIV was associated with an increase in wheezing in children ages 18 to 35 months who had a history of wheezing; though in the U.S. LAIV is not approved for children under 2 years of age and “should not be used” in children 2-4 years of age with a history of wheezing or asthma in the previous year 18. Two studies of the 2013-2014 and 2014-2015 flu seasons in the United Kingdom study found that LAIV was well tolerated among those with well-controlled asthma or recurrent wheezing 19,20. A prospective observational cohort study found an increased risk of wheezing among California children 2-4 years of age during the 42-day risk interval after receiving quadrivalent LAIV during the 2013–2014 influenza season 21.
Analysis of a survey of 1875 primary school children in the Netherlands found no association between receiving DTP-IPV vaccine and asthma or other atopic disorders (e.g., hay fever, eczema, food allergy) 22. A nested case-control study of Dutch and German children found no relationship between vaccination against pertussis, measles, rubella, or Hib and atopic disease or respiratory symptoms 23. A self-controlled case series of US infants born prematurely found no increased risk of wheezing lower respiratory diseases associated with DTaP, IPV, Hib, varicella, PCV7, MMR, or TIV vaccination (and live attenuated vaccinations even seemed to provide a temporary protective effect) 24. An Australian cohort study found a reduced risk of asthma (at 6 years of age) among children who received OPV (RR: 0.60; 95%CI:0.37-0.98) and an increased risk of asthma among children who received diphtheria-tetanus vaccines (not currently used in the US) (RR 1.76; 95%CI 1.11-2.78); associations were not found for other vaccinations routinely administered in the first two years of life 25. A 2021 Cochrane review found no evidence to support an association between MMR vaccination and asthma 26. Some studies suggest a possible protective effect of MMR vaccination against asthma 27-29, including a 2021 systematic review and meta-analysis 30. Two Canadian cohort studies assessing the potential association between influenza vaccination during pregnancy and childhood asthma found mixed results; one found a weak association (aHR: 1.05; 95% CI: 1.02-1.09) 31, while the other found no association 32.
A 2002 Vaccine Safety Datalink (VSD) study did not find an association between asthma and diphtheria, tetanus and whole cell pertussis vaccine (relative risk: 0.92; 95% confidence interval: 0.83-1.02), oral polio vaccine (RR: 1.09; 95% CI: 0.90-1.23), or measles mumps and rubella (MMR) vaccine (RR: 0.97; 95% CI: 0.91-1.04); weak associations were found with Haemophilus influenzae type b (Hib) vaccine (RR: 1.18; 95% CI: 1.02-1.36) and hepatitis B vaccine (RR:1.20; 95% CI: 1.13-1.27) 33. A 2020 Japanese cohort study found an increased prevalence of asthma, wheeze, and eczema among children receiving more inactivated vaccines 34. A 2022 VSD study found an association between aluminum adjuvanted vaccines and persistent asthma among both children with eczema (adjusted hazard ratio: 1.26 per 1 mg increase in aluminum; 95% CI: 1.07-1.49) and children without eczema (aHR 1.19; 95% CI: 1.14-1.25). However, these limited observational data are insufficient to draw clear causal conclusions 35.
Proposed biological mechanism
Respiratory syncytial virus (RSV) in infancy has been shown to increase the risk of asthma in childhood, as well as contribute to asthma exacerbation 36-39. Other natural viral respiratory infections such as influenza can also contribute to asthma exacerbation, as these viruses enter and replicate within airway epithelial cells, causing damage and initiating an immune response. Natural influenza infection also causes greater morbidity in asthmatic subjects than in the general population, perhaps due to a difference in the antiviral response of asthmatics 40.
The 2012 IOM report described cases of asthma exacerbation after both inactivated and live attenuated influenza vaccination 41; however, even after considering knowledge about the aforementioned natural infection, the IOM concluded that this mechanistic evidence was weak 1.
Animal studies suggest that aluminum adjuvants could impact allergy risk through inducing a T helper 2 cell (Th2) immune response 42,43. In allergic asthma, Th2 lymphocytes mediate airway inflammation and hyper-responsiveness 44. Exposure to aluminum through vaccination could bias the immune profile toward Th2 immune responses, thus theoretically increasing risk of allergic diseases such as asthma 35.
* These conclusions do not necessarily consider vaccines recommended only for special populations in the United States such as Yellow Fever vaccine (international travelers) or Smallpox vaccine (military personnel), or vaccines no longer recommended to the public such as the Janssen (J&J) COVID-19 vaccine.
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