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 (AAN) published “Update: Vaccine-preventable Infections and Immunization in Multiple Sclerosis,” which provides recommendations for clinicians. The full guideline
and clinician summary
are available online.
COVID-19 Vaccine Guidance for People Living with MS
The National MS Society convened a an group of MS and immunology experts to develop COVID-19 vaccine guidance for people living with MS, which has been published at the link above and will be progressively elaborated over time. Guidance for healthcare providers specific to the timing of the vaccine in coordination with disease modifying therapies and high-dose steroids is currently being developed by this same expert group. This information will be disseminated to healthcare providers by email, through webinars (time/date TBD) and through our healthcare provider Twitter account @mssocietyHCP.
2020-2021 Seasonal Flu Vaccine
The composition of US influenza vaccine is reviewed annually by the Centers for Disease Control and Prevention (CDC) and updated to match circulating influenza viruses. Routine annual influenza vaccination is recommended by the CDC for everyone over 6 months of age with rare exception.
The following recommendation is from the AAN guideline specific to the influenza vaccine:
- 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 have 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delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active (e.g., the relapse is no longer progressive but may be associated with residual disability).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 2020-2021 seasonal flu vaccine, please visit the CDC website
Hepatitis B vaccine
Human papillomavirus vaccine (Gardasil
- The hepatitis B vaccine is recommended for all infants, unvaccinated children under the age of 19 and adults at risk of contracting this potentially life-threatening disease.
- 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.
Pneumococcal vaccines (Pneumovax® 23 - PPSV23 and Prevnar® 13-PCV13)
- This vaccine is indicated in girls and women ages 9 to 26 and is designed to prevent the HPV 6, 11, 16 and/or 18-related cervical cancer, cervical dysplasias, vulvar and vaginal dysplasias later in life.
- 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.
Shingles vaccine (Shingrix®)
- PCV13 protects against 13 types of pneumococcal bacteria; PPSV23 protects against 23 types of pneumococcal bacteria.
- One dose of PPSV23 is recommended for all adults 65 years or older.
- 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 (Zostavax®)
- The CDC recommends Shingrix, a non-live vaccine for the prevention of herpes zoster (shingles) and related complications. The vaccine is recommended over Zostavax® (the previously approved vaccine for shingles) and is approved in adults 50 years of age and older.
- 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.
- Zostavax, is a live-virus vaccine to prevent shingles. MS healthcare providers 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.
- As of July 1, 2020, Zostavax is no longer being produced, but may still be used until the supply expires on November 18, 2020.
- 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.
- This vaccine should be considered by people with MS who have never had chicken pox, lack evidence of prior immunity, and are considering starting a disease modifying therapy (DMT) that has the potential to suppress cell mediated immunity. Refer to the prescribing information for each DMT and the varicella vaccine.
Studies of Vaccine Safety and Effectiveness in People with MS
Some, but not all, immunizations have been evaluated for safety and efficacy in people with MS:
- A study by the Vaccines in Multiple Sclerosis Study Group published in 2001 in the New England Journal of Medicine 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 by the National Immunization Program of the Centers for Disease Control and Prevention, published in the Archives of Neurology in 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 in 2011, of people with relapsing-remitting MS who received the yellow fever vaccination prior to travel, found a significantly increased risk of MS relapses 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 – which is a potentially fatal illness.
- A study of nearly four million females aged 10 to 44 years identified in nationwide patient registries in Denmark and Sweden, published in the Journal of the American Medical Association, found no increased risk of developing MS among nearly 800,000 who received quadrivalent human papillomavirus vaccine (Gardasil®), designed to prevent cervical cancer.
- A review of data from the complete electronic medical health records of Kaiser Permanente Southern California between 2008 and 2011, published in JAMA Neurology, found no long-term association of vaccines with MS or any other acquired central nervous system demyelinating disease.
- A meta-analysis and systematic review published in 2021 in Multiple Sclerosis and Related Disorders found people with MS developed adequate immune response to the influenza vaccine as compared to controls without MS.