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Overview

Many people with MS have concerns about the safety of routine vaccinations. This document provides recommendations based on the best-available evidence.

  • Immunizations and Multiple Sclerosis, a clinical practice guideline published by the Multiple Sclerosis Council for Clinical Practice Guidelines in 2001, presents conclusions based upon the research data available up to that time. The expert panel used the recommendations of the Centers for Disease Control and Prevention (CDC) as a foundation for the development of its guideline. The CDC has developed guidelines for immunizations for all adults. The consensus of the panel, based on the available research data, was that people with MS should not be denied access to health-preserving and potentially-life saving vaccines because of their MS, and should follow the CDC guidelines for any given vaccine.
  • Some, but not all, immunizations have been evaluated for safety and efficacy in people with MS:
  • A study published in the New England Journal of Medicine (Confavreux et al., 2001) found that vaccination for tetanus, hepatitis B, or influenza did not appear to increase the short-term risk of relapses (also called attacks or exacerbations) in people with MS.
  • A study published in the Archives of Neurology (DeStefano et al., 2003) found that vaccination against hepatitis B, influenza, tetanus, measles, or rubella did not increase a person’s risk of developing MS or optic neuritis (which is often a first symptom of MS).
  • A small, unblinded study published in the Archives of Neurology (Farez & Correale, 2011) of people with relapsing-remitting MS who received the yellow fever vaccination prior to travel found a significantly increased risk of MS relapse during the six weeks following the vaccination when compared to the remainder of the two-year follow-up period. For people with MS who must travel to areas where yellow fever is common, the increased relapse risk needs to be carefully weighed against the likelihood of exposure to yellow fever, a potentially fatal illness.
  • Other immunizations, such as those for pneumonia, meningitis, typhoid, polio, hepatitis A, human papillomavirus (HPV), and pertussis, do not have published studies addressing their safety in MS.

Specific vaccines

  • The varicella vaccine may be specifically considered for people with MS who: have never had chicken pox, lack evidence of prior immunity, and are considering starting an MS medication that has the potential to suppress cell mediated immunity. The vaccine should be taken well before starting the therapy.
  • The 2013-2014  Injectable Seasonal Flu Vaccine (includes H1N1)
    • The 2013-2014 seasonal influenza (flu) immunization is a single preparation that provides immunity to three different flu virus strains. It contains an H3N2 virus, an influenza B virus, and this year's H1N1 virus, which means that onely one "shot" is needed.
    • The injectable flu vaccine, which is an ‘inactivated’ vaccine, is recommended for everyone over 6 months of age. It has been studied extensively in people with MS and is considered quite safe. The injectable flu vaccine may be taken by people who are taking an interferon medication, glatiramer acetate, mitoxantrone, natalizumab, fingolimod, teriflunomide, or dimethyl fumarate. Although there were early concerns that the vaccine might not be as effective in people taking natalizumab or fingolimod, data (Vagberg et al., 2012; Mehling et al., 2011) suggest that people taking those medications do mount an effective immune response to the vaccine. A recent study (Bar-Or et al., 2013) also confirmed the effectiveness of the vaccine in people taking teriflunomide. No similar study has been done to date with dimethyl fumarate; however, there is nothing about its mechanism of action that would interfere with the efficacy of the vaccine. 
    • People who are experiencing a serious relapse that affects their ability to carry out activities of daily living should defer vaccination until 4-6 weeks after the onset of the relapse.
    • FluMist® is a live-virus flu vaccine(sometimes called LAIV for "live attenuated influenza vaccine”) that is delivered via a nasal spray. This live-virus vaccine is not recommended for people with MS. Live, attenuated vaccines are those whose biological activity has been reduced so that their ability to cause disease has been weakened but not totally inactivated.
    • A high-dose flu vaccine is available for people over age 65. This high-dose vaccine has not been studied in people with MS of any age. At present, the Centers for Disease Control is not recommending the high-dose vaccine over the seasonal flu vaccine for the general population.
  • The hepatitis B vaccine is recommended for all children, adolescents, and adults who are at risk of contracting this potentially life-threatening disease. In 2002, after carefully examining the published, peer-reviewed scientific and medical literature addressing the possible relationship between hepatitis B vaccination and diseases of the nervous system, the National Academy of Sciences’ Institute of Medicine (IOM) determined that there is no association between hepatitis B vaccination and the onset of multiple sclerosis.
  • The human papillomavirus vaccine – Gardasil® – is designed to prevent the HPV 6, 11, 16 and/or 18-related cervical cancer, cervical dysplasias, vulvar and vaginal dysplasias, and condyloma acuminate in girls and women 9 to 26 years of age. A recentcase report described the onset of acute disseminated encephalomyelitis following the second immunization with Gardasil (Waldemann et al., 2009) and Sutton et al. (2009) reported five patients who presented with multifocal or atypical demyelination syndromes within 21 days of the second or third immunization (three of whom had previously experienced clinical isolated episodes of neurological dysfunction). Pending the availability of further data, administration of Gardasil should be preceded by a thorough discussion between patient and physician of the possible benefits and risks.
  • The smallpox vaccine has never been studied in people with MS, and concerns about smallpox in the U.S. developed after the Clinical Practice Guideline was completed. This vaccine, however, is used to prevent a serious, generally fatal illness, and should be made available to any person with MS who is exposed to smallpox because the risks associated with not getting vaccinated would be too great. Because of the serious adverse events that can occur with this vaccine, however, it is the recommendation of Dr. Aaron Miller, one of the Society's National Medical Advisors, that no person with MS be given it unless he or she has been directly exposed to smallpox.
  • The information about the shingles vaccine -- Zostavax  -- isn't as clear-cut as it is for some other vaccines. In general, MS specialist neurologists do not recommend any live-virus vaccine for people with MS because live-virus vaccines can precipitate an increase in disease activity. However, Zostavax is somewhat unique because most people have had chicken pox earlier in their lives and therefore already have the virus in their bodies. If a person has had chicken pox or tests positive for the antibodies, this would likely be a safe and beneficial vaccine to take. However, each person needs to discuss the potential benefits and risks of this vaccine with her or his healthcare provider. In terms of the possible risks for a person with MS whose close family member receives this or any other live virus vaccine,  MS specialists are not in agreement. This is another decision the person with MS needs to discuss with her or his physician.

Special considerations

  • People who are experiencing a serious relapse that affects their ability to carry out activities of daily living should defer vaccination until 4-6 weeks after the onset of the relapse.
  • People on therapies that suppress the immune system (immunosuppressants), such as mitoxantrone, azathioprine, methotrexate, cyclophosphamide and/or chronic corticosteroid therapy should consult their neurologist before taking any live-virus vaccine. A person with a suppressed immune system would be at greater risk for developing the disease.
  • Inactivated vaccines are generally considered safe for individuals who are taking an interferon medication, glatiramer acetate, mitoxantrone, natalizumab, or fingolimod, teriflunomide or dimethyl fumarate.

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