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Immunization

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Overview

With the growing number of immunosuppressive and immunomodulating (ISIM) agents to treat MS there are more concerns around infection prevention and timing of vaccinations for people with MS. Many of these ISIM agents have specific vaccination recommendations within their prescribing information.

The American Academy of Neurology published “Update: Vaccine-preventable Infections and Immunization in Multiple Sclerosis,” which provides recommendations for clinicians. The full guideline and clinician summary are available online. 

Specific vaccines

2019-2020 Seasonal Flu Vaccine 

The composition of US influenza vaccine is reviewed annually by the Centers for Disease Control (CDC) and updated to match circulating influenza viruses. Routine annual influenza vaccination is recommended by the CDC for everyone over 6 months of age who does not have a contraindication.

The following recommendations are from the American Academy of Neurology Practice Guideline Update: Vaccine-preventable Infections and Immunization in Multiple Sclerosis

  • Clinicians should recommend that patients with MS receive the influenza vaccination annually, unless there is a specific contraindication (e.g., prior severe reaction).
  • Clinicians should recommend against using live attenuated vaccines in people with MS who currently receive ISIM therapies or have recently discontinued these therapies. Some of these therapies also restrictions from the US Food and Drug Administration (FDA) for the timing of a live vaccine after discontinuing an ISIM therapy. Refer to the ISIM therapy’s prescribing information for specific requirements.
  • Clinicians should delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active (e.g., the relapse is no longer progressive but may be associated with residual disability).


To learn more about the 2019-2020 seasonal flu vaccine, please visit the CDC website.

Hepatitis B vaccine

  • The hepatitis B vaccine is recommended for all children, adolescents and adults at risk of contracting this potentially life-threatening disease.
  • Individuals at risk include anyone working in a job that involves contact with human blood, those who have diabetes and are under age 60, those who have sex with or live in the same house as a person with hepatitis B virus infection, and those who have sex with more than one partner. Additionally, people who live or travel outside the country for more than 6 months a year are also advised to get this vaccine.
  • In 2002, the National Academy of Sciences' Institute of Medicine (IOM) determined that there is no association between hepatitis B vaccination and the onset of MS. 

Human papillomavirus vaccine (Gardasil®).

  • This vaccine 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 ages 9 to 26.
  • One case report (Waldemann et al., 2009) described the onset of acute disseminated encephalomyelitis following the second immunization with Gardasil, 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). However, a recent large-scale study of patient registries in Denmark and Sweden (see below) found no increased risk of developing MS among nearly 800,000 who received this vaccine. Use of Gardasil should be preceded by a discussion between patient and physician regarding benefits and risks.

Pneumococcal vaccines (Pneumovax® 23 - PPSV23) and Prevnar® 13-PCV13)

  • PCV13 protects against 13 types of penumococcal bacteria; PPSV23 protects against 23 types of pneumococcal bacteria.
  • One dose of PDV13 is recommended for all adults 65 years or older who have not previously received the vaccine. A dose of PPSV23 should be given at least one year later.
  • For adults 65 and older who have already received one or more doses of PPSV23, the dose of PCV13 should be given at least one year after receiving the most recent dose of PPSV23.
  • Both pneumococcal vaccines are inactivated and safe for people with MS.
  • According to the AAN recommendations on immunizations for people with MS, pneumococcal vaccine should be considered for individuals with compromised pulmonary function, including those who use a wheelchair on a full-time basis or are bed-bound.

Shingles vaccine (Shingrix®)

  • The CDC recommends Shingrix, a non-live vaccine for the prevention of herpes zoster (shingles) and related complications. The vaccine, which is given in two doses separated by 2 to 6 months, is recommended over Zostavax® (the previously approved vaccine for shingles). Shingrix is approved for adults 50 years and older:

    • whether or not they have had a prior episode of herpes zoster or have had a dose of Zostavax

    • who have a chronic medical condition, unless there is a specific reason why the individual should not have it

    • who are getting other adult vaccines such as influenza and pneumococcal (pneumonia) vaccines

  • No studies of Shingrix have been done in people with MS. However, in two clinical studies with Shingrix, there was no increase in immune-mediated conditions.

  • The CDC indicates that a person who is taking a low-dose immunosuppressive therapy or is going to begin taking an immunosuppressive medication can take Shingrix. It is very important to discuss this vaccine with the healthcare provider who is treating your MS to ensure that it is appropriate for you.

Shingles vaccine (Zostavax®)

  • Zostavax, is a live-virus vaccine to prevent shingles. MS neurologists do not recommend live-virus vaccines for people with MS because these vaccines can lead to an increase in disease activity. However, Zostavax is an exception because most people have had chicken pox earlier in their lives and therefore already have the virus in their bodies. Each person needs to discuss the potential benefits and risks of this vaccine with her or his healthcare provider.

Smallpox vaccine

  • While this vaccine has not been studied in people with MS, it should be made available to any person with MS directly exposed to smallpox as the risks associated with not getting vaccinated would be too great.

Varicella vaccine

  • This vaccine should be considered by 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 – for example, Gilenya® (fingolimod) and Lemtrada™ (alemtuzumab).
  • The vaccine should be taken six weeks before starting the MS therapy.

Special considerations

  • Clinicians should delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active (e.g., the relapse is no longer progressive but may be associated with residual disability), often many weeks after relapse onset.
  • Clinicians should recommend against using live attenuated vaccines in people with MS who currently receive ISIM therapies or have recently discontinued these therapies.
  • A person should not receive a live-virus vaccine following a course of Lemtrada®.
  • Because vaccination with live-attenuated or live vaccines is not recommended during treatment and after discontinuation until B-cell repletion, administer all immunizations according to immunization guidelines at least 4 weeks prior to initiation of Ocrevus® for live or live-attenuated vaccines and, whenever possible, at least 2 weeks prior to initiation of Ocrevus for non-live vaccine. For important information on the vaccination of infants born to mothers treated with Ocrevus during pregnancy visit our web page on reproductive issues.
  • Patients without a healthcare professional confirmed history of chickenpox or without documentation of a full course of vaccination against varicella zoster virus (VZV) should be tested for antibodies to VZV before initiating Mayzent® treatment. A full course of vaccination for antibody-negative patients with varicella vaccine is recommended prior to commencing treatment with Mayzent®, following which initiation of treatment with Mayzent® should be postponed for 4 weeks to allow the full effect of vaccination to occur. The use of live attenuated vaccines should be avoided while patients are taking Mayzent® and for 4 weeks after stopping treatment. Vaccinations may be less effective if administered during Mayzent® treatment. Mayzent® treatment discontinuation 1week prior to and until 4 weeks after a planned vaccination is recommended.
  • Vaccination of patients who are antibody-negative for varicella zoster virus is
    recommended prior to initiation of Mavenclad®. Administer all immunizations according to immunization guidelines prior to starting Mavenclad®. Administer live-attenuated or live vaccines at least 4 to 6 weeks prior to starting Mavenclad®, because of a risk of active vaccine infection. Avoid vaccination with live-attenuated or live vaccines during and after Mavenclad treatment while the patient’s white blood cell counts are not within normal limits.
  • MS experts are not in agreement about the risks for a person with MS whose close family member receives a live-virus vaccine. The family should discuss with the neurologist how best to handle this situation. 

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