Multiple Sclerosis and immunisation

Vaccination for people with MS needs to be planned: MJA.
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The immunisation status of patients newly diagnosed with multiple sclerosis (MS) must not be overlooked when beginning treatment with immunomodulatory or immunosuppressive disease-modifying therapies (DMTs), according to the authors of a Perspective published 19 April by the Medical Journal of Australia.

“Determining immunisation status when commencing DMTs is key, as is an individualised approach to risk–benefit assessment when considering vaccinations,” wrote the authors, led by Dr Cassie Nesbitt, a neurologist at Alfred Health in Melbourne.

“MS is an autoimmune disorder treated with DMTs. Immunosuppression predisposes [patients with MS] to infection risk, including opportunistic infections; a higher long-term risk of some infection-related malignancies is also likely. 

“Infections in patients with MS may result in increased relapses, functional decline and pregnancy complications.”

Early planning was vital, Nesbitt and colleagues wrote.

“A full course of vaccinations should be considered for non-immune patients before commencing a DMT; this is sometimes forgotten in the urgency of managing a new MS diagnosis.

“Live vaccinations use an attenuated viral or bacterial strain and are contraindicated with most DMTs because of the risk of disseminated infection when used in immunocompromised states. Administration of live vaccines is recommended before DMT commencement,” they wrote.

“Routine vaccinations are not associated with increased MS relapse risk,10 although the risk of relapse associated with yellow fever vaccination remains unclear. 

“Immunisations administered in accordance with local guidelines are considered the best strategy for minimising the risk of infections that could trigger MS relapses. In patients experiencing clinically significant relapses, delaying vaccine administration has been suggested until patients have stabilised and show signs of improvement (typically 4–6 weeks).

“Additional consideration is required for women with MS who are planning a pregnancy,” they wrote. 

“Women should receive live vaccinations before conception to prevent adverse pregnancy outcomes; however, DMT cessation to allow vaccination before conception is often not feasible. Vaccination should therefore be explored as early as possible, preferably before commencement of DMT, as it may represent a one-off opportunity.”

The Perspective also provides guidance on the following vaccines:

• Influenza (non-live);
• Primary varicella (live);
• Varicella zoster reactivation (live);
• Measles–mumps–rubella (live);
• Pneumococcus (non-live);
• Hepatitis B virus (non-live);
• Diphtheria–tetanus–pertussis (non-live);
• Meningococcal disease (non-live);
• Yellow fever (live);
• Human papillomavirus (non-live); and,
• Travel vaccines.

“Live vaccinations are contraindicated in patients once they have commenced a DMT,” Nesbitt and colleagues concluded. 

“Although we consider it safe to combine non-live vaccinations with DMTs, data are limited regarding their efficacy and durability.”

Associate Professor Anneke van der Walt, the senior author on this study, will also be leading a study to determine if people with MS (pwMS) on different MS treatments will develop sufficient protective immune responses after receiving a Covid-19 vaccine. She and the MSNI Unit at The Alfred will be collaborating with A/Prof Fabienne Brilot from Sydney Children’s Health Network. 

She said, "This is important to determine as MS treatments generally suppress the immune system and a normal response to a vaccine may be blunted or diminished.  The study aims to also determine how long the effect of the vaccine last for pwMS on treatments. Lastly, we will be determining if pwMS will be protected from the new strains of the Covid-19 virus after receiving a vaccine." 

There are several MS clinics in Australia that will be participating.  If anyone is interested in participating please discuss it with your neurologist first.

Reference:

Nesbitt C, Rath L, Zhong M, Cheng AC, Butzkueven H, Wesselingh R, Skibina O, Monif M, Yeh Wei, Brotherton JML, Reddel S, van der Walt A.  Vaccinations in patients with multiple sclerosis: review and recommendations. MJA 19 April 2021. https://doi.org/10.5694/mja2.51012