Multiple Sclerosis Centers of Excellence
Vaccines and Multiple Sclerosis: A Practical Guide
Kathy Tortorice, PharmD -- VA National Pharmacy Benefits Management Service
Vaccines are important for preventing other illnesses. Preventive care is also an important part of MS management. You may wonder about links between MS and vaccines. Are vaccines safe to use in people with MS? Do vaccines cause MS? Are they safe for me? Should I have them? This article clarifies that vaccines do not cause MS and guides you in how vaccines are used safely by people with MS.
Why are vaccines important?
Vaccines are an important way to protect everyone from serious infectious diseases. Today’s vaccines are among the most successful and cost-effective public health tools available for preventing diseases. Thanks to vaccines, serious and often fatal diseases like polio are now distant memories for most Americans. In almost all cases, getting a vaccine is much safer than getting the disease itself. Currently, vaccines to protect children and adults from at least 17 diseases are available. Travelers to foreign countries, where uncommon diseases such as typhoid and yellow fever may be encountered, may need additional vaccines before their trips. Guidelines on vaccinations for people with MS have been established by the MS Council for Clinical Practice and by the U.S. Centers for Disease Control (CDC).
Several types of vaccines are available. Live, attenuated vaccines contain a version of the living microbe that has been weakened so it does not cause disease. Although live, attenuated vaccines are generally very effective, because they contain live microbes, they should not be given to people with damaged or weakened immune systems, such as those with HIV. Since there may be an increased risk with live, attenuated vaccines in people taking certain MS disease modifying medications, people taking these medications should avoid live, attenuated vaccines when an alternative is available.
Vaccines that are not live are inactivated (contain microbes killed by chemicals, heat, or radiation), subunits (contain only part of the microbe), toxoids (inactivated toxins), or conjugate (a subunit linked to a toxoid) vaccines. These non-live vaccines cannot cause disease and are therefore generally safe for use in people with MS. In addition to the active component of the vaccine (the part that induces disease protection), vaccines contain other substances. Anyone with a severe, life-threatening allergy to any component of a vaccine should not get that vaccine.
One of the most commonly used vaccines is influenza (flu) vaccine. Flu vaccines are one of the most important ones we should all be sure to get, because flu can be unpleasant and even fatal. There are several types of flu vaccine. The most familiar and commonly used one is the standard flu shot. The standard flu shot is an inactivated vaccine containing only killed flu viruses. The injectable flu vaccine is recommended for everyone over six months of age. It has been studied extensively in people with MS and is very safe. A high-dose, injected flu vaccine is available for people over age 65. This high-dose vaccine is also an inactivated vaccine. It has not been studied in people with MS and, at present, the CDC is only recommending the high-dose vaccine over the seasonal flu vaccine for people 65 years of age or older.
There are some people who have never had chickenpox or the chickenpox vaccine. Because fingolimod, alemtuzumab, and ocrelizumab can increase the risk of chickenpox in people with MS, if you are going to use fingolimod and have not had chickenpox or the vaccine, the CDC recommends that you receive the varicella vaccination. The varicella vaccine is given in two doses four weeks apart. People with MS should not start fingolimod until at least one month after the last dose of the varicella vaccine.
The shingles vaccine protects people from shingles which is a reactivation of varicella zoster virus if you had chickenpox earlier in life. The CDC recommends adults 60 years or older receive the shingles vaccine. One of the shingles vaccines (Zostavax®) is a live vaccine; however, because most people have had chickenpox earlier in their lives and therefore already have the virus in their bodies, the risk of getting disease from the vaccine is much lower. The use of this vaccine requires a single, one-time subcutaneous injection. The other shingles vaccine (Shingrix®) is given by intramuscular injection requiring two injections, with the second dose given 2 to 6 months after the first. The CDC’s Advisory Committee on Immunization Practices (ACIP) now recommends Shingrix vaccine over Zostavax and suggests those who received Zostavax® in the past should be revaccinated with Shingrix for greater protection against shingles.
The pneumonia vaccine (Pneumovax 23® and Prevnar13®) protect people from pneumonia caused by the pneumococcus bacteria. The difference in the two vaccines is how many types of bacteria they target. The vaccines are non-live, subunit vaccines. The pneumonia vaccine is recommended for people with compromised breathing or lung function, such as those who are wheelchair-dependent or bedbound, because they are more prone to pneumonia. The CDC recommends that in order to acquire the best protection against all strains of bacteria that cause pneumonia, all adults 65 and older should receive the two pneumococcal vaccines. This vaccine is generally safe for people with MS.
Human Papilloma Virus Vaccine
This vaccine can prevent most cases of cervical cancer if given before a girl or woman is exposed to the virus. In addition, this vaccine can prevent vaginal and vulvar cancer in women and can prevent genital warts and anal cancer in women and men. The CDC now recommends teens and young adults who begin the vaccine series later, at ages 15 through 26, continue to receive three doses of the vaccine. Additionally, the CDC recommends catch-up HPV vaccinations for all people through age 26 who aren't adequately vaccinated. The U.S. Food and Drug Administration recently approved the use of Gardasil-9® for males and females ages 9 to 45.
Both hepatitis A and hepatitis B vaccines are not live and are safe for people with MS. If you have not had these vaccines during childhood or as a condition of employment, discuss it with your health care provider to see if you need them. The measles, mumps, and rubella (MMR) vaccine is a live, attenuated vaccine generally given during infancy, after 1 year of age, and is recommended by CDC for the general population. Tetanus vaccine, which is often given as a combined vaccination with diphtheria (Td) or with both diphtheria and pertussis (Tdap), is not a live vaccine.
Overall, vaccines are safe and effective for people with MS and are important disease prevention tools. There are no concerns for use of non-live vaccines in people with MS. Live, attenuated vaccines should usually be avoided in people with MS when an effective, safe alternative is available. The use of live, attenuated vaccines should be avoided during and for two months after treatment with fingolimod because of the risk of infection. Additionally, vaccines should not be given during therapy with daclizumab, alemtuzumab, and ocrelizumab. If a live vaccine is required, therapy with these agents should not begin until 8 weeks after the vaccination. The risk of live, attenuated vaccines for people taking a DMT is uncertain; people on these medications should discuss the potential risk and benefits of live, attenuated vaccines, such as Zostavax®, with their health care provider. Vaccines should not be given during or within 4-6 weeks of an MS relapse. If you have any questions or concerns, please talk with your health care provider.