Updated Vaccination Recommendations for People with Multiple Sclerosis

Key Recommendations

Recommendation 1: Use of Live Attenuated Vaccines

• Safe Use: Live attenuated vaccines can be safely administered to MS patients not on DMTs or those receiving immunomodulatory treatments like interferons or glatiramer acetate (GA).
• Avoid Use: Live attenuated vaccines should be avoided in patients receiving the following therapies:
• Dimethyl fumarate (DMF)
• Teriflunomide
• Sphingosine-1-phosphate modulators
• Natalizumab
• Cladribine
• Alemtuzumab
• Anti-CD20 monoclonal antibodies (e.g., ocrelizumab, rituximab)

Recommendation 2: Immunization Status Evaluation

All MS patients, regardless of their initial therapeutic plans, should undergo an evaluation of their immunization status. This proactive approach helps minimize risks and ensures timely vaccination.

Recommendation 3: Patient-Centred Communication

Healthcare providers should:

• Educate patients on the importance of vaccination and the risks of non-vaccination.
• Consider patients’ values, preferences, and potential concerns regarding immunization.
• Develop personalized immunization plans, allowing for informed decisions, including the option to decline vaccination.

Recommendation 4: Early Vaccination

Vaccination should ideally be performed at the time of diagnosis or in the early stages of MS. This approach helps prevent future delays in starting DMTs.

Statements on Vaccination Efficacy

Statement 1: Efficacy in MS Patients without DMT or on Interferons and GA

The level of protection achieved after vaccination in these patients is similar to that of the general population.

Statement 2: Efficacy in Patients on DMF, Teriflunomide, and Natalizumab

While antibody production may be lower compared to non-treated patients or those on interferons, sufficient seroprotection is generally achieved.

Statement 3: Efficacy in Patients on Sphingosine-1-Phosphate Modulators and Anti-CD20

Patients on these therapies exhibit lower antibody production than non-treated patients or those on interferons, leading to reduced seroprotection.

Statement 4: Efficacy in Patients on Alemtuzumab and Cladribine

Limited data are available on the protection achieved after vaccination in these patients. However, due to the drugs’ mechanisms of action, reduced seroprotection is expected until complete immune reconstitution occurs.

Statements on Vaccine Safety

Statement 1: Relapse Risk

Vaccines are not associated with an increased risk of MS relapses, regardless of DMT status.

Statement 2: Disability Risk

There is no evidence suggesting that vaccines increase the risk of disability in MS patients.

Statement 3: Benefit-Risk Balance

The benefits of vaccination in MS patients significantly outweigh any potential risks.

Statement 4: Safety of Inactivated Vaccines

Inactivated vaccines can be safely administered to MS patients receiving DMTs.

Travel-Related Vaccination Recommendations

Recommendation 1: Early Discussion of Travel Plans

Care providers should discuss potential travel plans with MS patients as early as possible, especially with those who will start immunosuppressive therapies.

Recommendation 2: Consultation with Travel Clinics

MS patients planning to travel to tropical or subtropical destinations should be advised to consult a specialized Travel Clinic or a vaccination expert. This should be done in coordination with the MS specialist to provide an individualized evaluation and pre-travel immunization plan, considering the risk–benefit balance.

Recommendation 3: Consideration of Travel Details

Care providers should consider the timing and destination of travel to advise on the most appropriate immunization strategy.

Recommendation 4: Timing of Travel Vaccinations

Immunizations needed for travel should ideally be started 2 to 3 months before departure. When necessary, accelerated vaccination schedules can be applied if available.

Recommendation 5: Post-Vaccination Serology

For MS patients receiving immunosuppressive therapies, post-vaccination serology should be verified for vaccines with established antibody cut-off levels, such as hepatitis A, hepatitis B, rabies, tetanus, and polio. Additional booster doses may be required if antibody responses are inadequate.

Recommendation 6: Stopping Treatment for Live Vaccines

Care providers should discuss the risks and benefits of stopping immunosuppressive treatment to receive a live attenuated vaccine when travel requires it.

Reference : Rieckmann P, Boyko A, Havrdova E, Wiendl H, Gold R. ECTRIMS/EAN consensus on vaccination in people with multiple sclerosis: Improving immunization strategies in the era of highly active immunotherapeutic drugs. Mult Scler. 2023. doi:10.1177/13524585231168043

https://doi.org/10.1177/13524585231168043