Association between Vaccinations and MS:
Current research, including numerous case-control studies, generally does not support a connection between vaccinations and the onset of multiple sclerosis (MS). A nested case-control study (Langer-Gould 2014) found no association between the Hepatitis B (HepB) vaccine, the human papillomavirus (HPV) vaccine, or any other vaccines and the risk of developing MS or other central nervous system demyelinating diseases in the following three years. Additionally, a systematic review (Farez, Correale 2011) found no increased risk of MS following vaccinations for BCG, Hepatitis B, Influenza, and Measles-Mumps-Rubella (MMR), and noted that the risk of MS appeared to be reduced after tetanus or diphtheria vaccinations.
Vaccinations and Relapse Risk in MS:
There is no evidence suggesting that vaccinations cause or precipitate relapses in individuals with MS. A practice advisory by the American Academy of Neurology (Rutschmann et al 2002) found strong evidence against the increased risk of MS exacerbation following influenza immunization. A randomized trial of influenza vaccination in relapsing MS patients showed no difference in relapse rates between the vaccinated and placebo groups (Miller et al 1997). Based on this, it is generally recommended that people with MS receive the influenza vaccine (excluding FluMist, the live nasal spray form).
Recommendations for Vaccinations in Adults with MS:
Adults with MS are encouraged to follow the standard immunization schedule appropriate for their age, unless they are on specific medications affecting vaccination response. MS patients should ideally avoid live attenuated vaccines when possible, as their efficacy is theoretically reduced due to the compromised immune response associated with MS therapies. However, inactivated vaccines are typically safe for MS patients, including those on disease-modifying therapies (DMTs).
Vaccines to Avoid:
Live attenuated vaccines, such as those for measles, mumps, rubella (MMR), chickenpox, and the nasal spray influenza vaccine (FluMist), are generally not recommended for people with MS. Although the risk associated with live vaccines is theoretical, they may pose a greater risk for individuals on immunosuppressive treatments. In contrast, inactivated vaccines are safe and effective for MS patients, including those on interferon treatments or other DMTs.
Effect of Disease-Modifying Therapies (DMTs) on Vaccination:
Certain DMTs, like corticosteroids and fingolimod, can affect the immune system’s response to vaccines. Corticosteroids, particularly when used long-term, may reduce vaccine efficacy. It is recommended to delay vaccinations for at least 6 weeks after a steroid pulse. Fingolimod, a sphingosine 1-phosphate receptor modulator, can reduce the immune response to vaccines, and patients should check their immunity before starting this therapy, especially for varicella zoster. Similarly, live vaccines should be avoided after starting treatments like alemtuzumab (Lemtrada) due to immune suppression caused by T and B cell depletion.
Vaccination and Relapse in MS:
People with MS who experience a serious relapse affecting daily functioning should defer vaccinations for 4-6 weeks after the onset of the relapse. Limited data is available on the impact of immunizations during a relapse, but it is generally advisable to wait for stability before proceeding with vaccination.
Shingles Vaccine for Older Patients with MS:
There is no high-quality evidence regarding the safety and efficacy of the shingles vaccine (Zostavax) in MS patients. However, the general recommendation at the Mellen Center is for MS patients to receive this vaccination unless they are on immunosuppressive therapies, which could compromise the immune response.
Travel Vaccinations for MS Patients:
Travel vaccinations should be considered with caution for MS patients, especially those on immunosuppressive treatments. It is important for MS patients traveling to areas at risk for diseases like yellow fever or malaria to consult with an infectious disease specialist before getting vaccinations. For those on DMTs such as alemtuzumab or rituximab, travel vaccination should be carefully managed due to potential immune system effects.
Summary of Key Vaccinations for MS Patients:
- Influenza vaccine (inactivated) is recommended for all MS patients, but FluMist (live vaccine) should be avoided.
- Hepatitis B vaccine is safe and recommended.
- Human papillomavirus vaccine (Gardasil): No increased risk of MS was found in a large-scale study.
- Shingles vaccine (Zostavax): Recommended for older patients with MS unless they are on immunosuppressive therapy.
- Varicella vaccine: Should be given before initiating certain DMTs like fingolimod or alemtuzumab.
- Tetanus, Hepatitis B, and other vaccines: Generally safe and effective for MS patients.
Conclusion:
In general, people with MS should receive routine vaccinations, avoiding live attenuated vaccines when possible. Consultation with healthcare providers is key, especially for those on immunosuppressive therapies, to ensure safe and effective vaccination practices.