Overview

Many people with MS have concerns about the safety of routine vaccinations and vaccinations required for travel to other countries. In general, it is recommended that people with MS receive vaccines according to the standard vaccine schedule.

General recommendations

Experts from the Academy of Neurology (AAN) reviewed the available scientific evidence on infections and vaccine use in multiple sclerosis and made recommendations in Practice Guideline: Infections and Vaccine use in Multiple Sclerosis. Key messages from the Guideline include:

• Preventing infections through vaccine use is a key part of medical care for people with MS.
• People with MS should receive vaccines according to standard vaccine guidelines.
• Before receiving any vaccine, you should talk with your healthcare provider about any MS medicine you are using.

For specific recommendations on vaccinations, view the Center for Disease Control and Prevention’s Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2020.

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.

• Inactivated vaccines are generally considered safe for people with MS, including those who are taking an interferon medication (Avonex®, Betaseron®, Extavia®, Plegridy®, Rebif®), Aubagio®, Copaxone®, Gilenya®, Glatopa®, Lemtrada®, Novantrone®, Tecfidera® or Tysabri®.
• Live and live-attenuated vaccines are generally not recommended for people with MS.
• People on therapies that suppress the immune system, such as Cytoxan®, Imuran®, Novantrone®, Rheumatrex® and/or chronic corticosteroid therapy, should consult their neurologist before taking any live-virus vaccine.
• A person should not receive a live-virus vaccine following a course of Lemtrada®.
• Any required live and live-attenuated vaccinations should be administered at least 4 weeks before a person starts treatment with Ocrevus®. No live-attenuated or live vaccines should be given during treatment or following treatment until your healthcare providers tells you that your immune system is no longer weakened. When possible a person should receive any non-live vaccines at least 2 weeks before you start treatment with Ocrevus. If you would like to receive any non-live (inactivated) vaccines, including the seasonal flu vaccine, while being treated with Ocrevus, talk to your healthcare provider. If you are pregnant or planning to become pregnant after receiving Ocrevus talk to your healthcare provider about vaccinations for your baby, as some precautions may be needed.
• You should avoid receiving live vaccines during treatment with Mayzent®. Mayzent® should be stopped 1 week before and for 4 weeks after receiving a live vaccine. If you receive a live vaccine, you may get the infection the vaccine was meant to prevent. Vaccines may not work as well when given during treatment with Mayzent®.
• You should not receive live or live attenuated vaccines within the 4 to 6 weeks preceding your treatment with Mavenclad®. You should not receive these types of vaccines during your treatment with Mavenclad® and until your healthcare provider tells you that your immune system is no longer weakened.
• 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.

Information about Specific Vaccines

2019-2020 Seasonal Flu Vaccine

The composition of U.Sl influenza (flu) vaccines is reviewed annually by the Centers for Disease Control and updated to match circulating flu viruses.

• Routine annual influenza (seasonal flu) vaccination is recommended by the CDC for everyone over 6 months of age who does not have a specific reason they cannot get the vaccine. The AAN recommends that people with MS should receive the annual influenza vaccine unless they have a specific reason they cannot get it.
• The FluMist (nasal spray) vaccine for the seasonal flu is a live vaccine. The AAN recommends against using live vaccines in people with MS who are currently taking a disease modifying therapy (DMT). For some DMTs, there are also restrictions from the US Food and Drug Administration (FDA) for the timing of a live vaccine after discontinuing a DMT. Prior to receiving a live vaccine, discuss the risks, benefits and appropriate timing with your MS healthcare provider.
• If you are experiencing a relapse, discuss the timing of your influenza vaccine with your MS healthcare provider. The AAN recommends waiting for the relapse to resolve before receiving any vaccinations.
• A high-dose inactivated flu vaccine (Fluzone High-Dose) is available for people over age 65. The CDC has not expressed a preference for any flu vaccine for people 65 and older. The high-dose vaccine has not been studied in people with MS of any age.

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. Note: Reports of an increase in MS cases in France following vaccination for hepatitis B frightened many people into avoiding hepatitis B vaccinations. However, these reports confused a temporal relationship (diagnosis of MS following the vaccine) with a causal relationship (the vaccine caused MS). MS experts are in agreement that the vaccine does not cause MS to occur. Hepatitis B is a serious illness that can safely be prevented with the hepatitis B vaccination.
• 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.

c 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. A 2017 systematic review of vaccine safety in MS concluded that the hepatitis B vaccine does not increase a person’s risk of developing 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 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 American Academy of Neurology 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
  • 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.

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.

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 girls and women 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 20011, published in JAMA Neurology, found no long-term association of vaccines with MS or any other acquired central nervous system demyelinating disease.

Studies of Vaccines with Specific Disease Modifying Therapies

• A blinded, randomized, multicenter, placebo-controlled study, published in Neurology in 2015, evaluated the effectiveness of the flu vaccine in fingolimod-treated patients. Researchers found that most fingolimod-treated patients with MS were able to mount immune responses with the vaccine, and the majority met criteria indicating seroprotection. However, response rates were reduced compared with placebo-treated patients. Overall, there was some decrease in vaccination-induced immune responses among the fingolimod treated patients.
• A study, published in Neurology in 2013, investigated the effect of teriflunomide on the efficacy and safety of the influenza vaccine and found that teriflunomide-treated patients generally mounted effective immune responses to seasonal influenza vaccination. Researchers concluded that teriflunomide generally does not adversely impact the ability of MS patients to mount immune responses to influenza vaccination.\A small case-control study, published in Neurology in 2013, assessed immunocompetence in patients after alemtuzumab treatment by measuring antibody responses to several vaccines before and after treatment. Researchers concluded that serum antibodies against common viruses remained detectable after treatment, and there was retained ability to mount an immune response against new antigens after treatment with alemtuzumab.
• In a small study published in Neurology, Neuroimmunology and Neuroinflammation in 2016, comparing people being treated with daclizumab with a group comprised of healthy controls and people with MS not being treated with daclizumab, no difference was found in the two groups’ ability to mount a normal antibody response to influenza vaccinations.