Guide to Vaccinations for People with MS
We commonly get questions about vaccinations or immunizations for people with multiple sclerosis (MS). Vaccinations are very important for health and have been proven to help prevent many different diseases which may in some cases cause severe illness, disability or even death. There is some information about the safety and effectiveness of many vaccines for people with MS, however information about many issues is incomplete. Concerns relate to whether vaccinations can trigger MS exacerbations, whether vaccines are effective when patients are taking certain immune medicines or steroids and whether vaccinations are safe for people with medicines that decrease immune function. In general people who are experiencing any relapse should defer vaccination until 4-6 weeks after the onset of the relapse.
It is important to recognize that vaccinations are created by different mechanisms and many types of vaccinations are made using killed organisms or using only portions of organisms and cannot cause actual infection. These are considered to be inactivated or component vaccines. Vaccinations may also be against a toxin that an organism creates (tetanus) and do not contain live organisms. A more concerning group of vaccines for people with MS are those that are produced using live but weakened organisms (live attenuated vaccines).
Should I get immunizations?
Our physicians currently recommend that when possible people with MS should not receive live attenuated vaccines. Infection is known to be a trigger for both MS exacerbations as well as worsening of MS symptoms without new lesions (pseudo-exacerbations). When possible we prefer people not receive the zoster vaccine, influenza nasal vaccine, yellow fever vaccine, typhoid vaccine, rotavirus, or oral polio vaccine. The MMR (mumps measles rubella) vaccine is a live attenuated vaccine however several studies have not detected increased relapse risk following its administration. However, MMR vaccine and the other above live/attenuated vaccines should be avoided in patients who are receiving immunosuppressive therapy as they may trigger harmful infection or chronic carrying of the weakened organism. The risk of infection and complications of infection must be balanced with other risks and should be discussed individually with your personal physicians, should live vaccine use be considered appropriate.
The use of killed, toxoid, subunit or conjugate vaccines would be expected to have less risk of aggravating MS and some studies have supported the safety of this type of vaccination. These vaccinations include influenza (injectable flu vaccines), tetanus, hepatitis B, hepatitis A, inactive polio vaccine, pneumococcal vaccine, human papilloma virus (HPV), Hamaenophilus influenza type B, Tick Borne-Encephalitis, Japanese B encephalitis, cholera, and rabies. There have been enough studies that Drs. Heyman and Zaydan encourage their patients with MS who need these vaccines (esp. tetanus, hepatitis B and the flu shot) to take them. They feel immunizations should help prevent infections which may trigger MS exacerbations.
Will immunizations work to prevent infection when I am on a disease modifying MS medication?
Information is incomplete about the effectiveness of vaccinations for people taking many MS disease modifying medicines. Small studies of interferon beta (Betaseron/Avonex/Rebif/Extavia) suggest that the flu vaccine is effective. Fingolimod (Gilenya) also appears not to decrease the effectiveness of injectable flu vaccine. Adequate studies with glatiramer acetate (Copaxone) natalizumab (Tysabri) and teriflunomide (Aubagio) have not been performed. Our physicians believe glatiramer acetate and natalizumab might not impair vaccine effectiveness but are uncertain about teriflunomide (Aubagio). It is highly likely that immunosuppressive therapy (chemotherapy-type drugs) sometimes used for MS and related disorders will decrease vaccine effectiveness. Because the rate of serious infections is higher when people are receiving immunosuppressive agents, vaccination should be discussed individually with your physician if you're receiving mitoxantrone (Novantrone), methotrexate, cyclophosphamide (Cytoxan), rituximab (Rituxan), azathioprine, mycophenolate mofetil (CellCept) and others. Effects of immunosuppressive medications may persist for months or longer after they have been stopped. Some immunizations may need to be repeated after very high potency immunosuppressive therapy, such as with bone marrow stem cell transplantation. It may be necessary to check antibody levels 4 weeks after vaccination is given (for some people with MS on the above agents) to determine vaccine effectiveness. IV IgG may impair the effectiveness of vaccines for up to 6-12 months after therapy with IVIG G has been discontinued.
Will steroid medications interfere with my vaccinations?
Steroid medications and ACTH are sometimes used for MS patients. The use of steroids and vaccinations in people with MS has not been completely addressed by research studies. A concern is that steroids will prevent the vaccination from working to fully protect against infection despite vaccination. We suggest that immunizations be delayed for at least 2 weeks following a brief (less than 2 week) course of steroids or ACTH therapy whenever possible. If steroids have been taken for more than 2 consecutive weeks, it is suggested that patients should wait at least 3 months after stopping steroids before administering a live-virus vaccine.
Must a MS patient avoid others who have recently received a vaccination?
Our main concern about people with MS is when their personal contacts have recently received a live /attenuated vaccination. People with MS should avoid contact with body fluids or secretions (including saliva and tears) from individuals who have recently received a live attenuated vaccine. Although they contain live attenuated virus, the Measles-mumps-rubella (MMR), varicella (Chicken Pox), rotavirus, and intranasal flu vaccines may be given when an immunosuppressed person with MS lives in the same house. Household contacts of immunosuppressed people with MS may receive the zoster vaccine if indicated as well. The oral polio vaccine should not be administered to any household contact of a person with MS on an immunosuppressive medication.
What if a person with MS is exposed to an infection they have not been vaccinated against?
For some infections, specific immune globulins may be indicated (especially for persons who have received immunosuppressive medications) instead of or in addition to vaccination. Discuss this with your physician if a question arises.