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Vaccines and Multiple Sclerosis: A Practical Guide

Kathy Tortorice, PharmD, BCPS

Vaccines have been the focus of the news lately. Many questions come up when discussing the importance of vaccines for maintaining our health. Vaccines protect us from diseases without us having to experience the actual disease. Currently, there are vaccines available to protect children and adults against at least 17 serious diseases. Let’s look at what vaccines are, who needs them, and some common questions or concerns people have about vaccines.

Vaccines are made using several different processes. They may contain (1) live viruses that have been attenuated (weakened or altered making them unable to cause illness); (2) inactivated or killed organisms or viruses; (3) inactivated toxins (for bacterial diseases where toxins generated by the bacteria, and not the bacteria themselves, cause illness), such vaccines are more stable and safer than live vaccines; or (4) merely segments of the pathogen (this includes both subunit and conjugate vaccines).

It is important to be up to date on your vaccinations before starting a disease modifying therapy (DMT) for your MS. Fingolimod (Gilenya) might increase the risk of a potentially life-threatening varicella zoster (VZV infections) so your provider will generally check for VZV antibodies before initiating fingolimod therapy. If immunity is not demonstrated by elevated VZV antibody levels, you will need the chicken pox (two-step) vaccination before starting fingolimod. It is recommended that you then wait one month after your last VZV immunization to let the vaccine work before starting fingolimod therapy.

Flu Vaccine

One of the most important vaccines is the influenza (flu) vaccine. Flu vaccines are important because flu is common, can be unpleasant, and can be fatal. The injectable flu vaccine has been studied extensively in people with MS and is considered safe for people getting a DMT for their MS. The flu vaccine is also available as an intranasal spray, Flu Mist, which should not be used in people with MS since it is a live vaccine. It is important to know that if a family members receives this intranasal vaccine, they will shed virus for up to one week after the vaccination. That means there is a possibility you can get the flu virus if you are exposed to their urine or feces during this period.

Chickenpox Vaccine

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.

Shingles Vaccine

The Shingrix vaccine is a subunit vaccine, meaning it provides part of the germ, that helps prevent shingles. Shingles is a painful outbreak of the varicella zoster virus (VZV), the same virus that causes chickenpox. Only a person who has previously had chickenpox can develop shingles. Shingles causes a painful rash and can result in persistent pain after the rash resolves. People with MS may be at higher risk of getting shingles because of reduced immune system function due to disease-modifying treatments. High-dose steroids, often used during relapses, may also increase the risk of a shingles outbreak. The Shingrix vaccine does not contain live virus and is safe for you to get. It is given by intramuscular injection requiring two injections, with the second dose given 2 to 6 months after the first.

Pneumonia Vaccine

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 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 approved the use of Gardasil-9 for males and females ages 9 to 45.

COVID-19 Vaccine

COVID-19 vaccines are an important component to preventing the spread of the COVID-19 virus. COVID-19 causes very serious illness and death, particularly to vulnerable people including those who are older, immunocompromised, and have certain medical conditions. If you get COVID-19, you also risk giving it to loved ones who may get very sick. COVID-19 vaccines were tested in large clinical trials to make sure they met safety standards. It is not possible to get COVID-19 from getting the vaccination.

There are several types of COVID-19 vaccines. One type is called a messenger RNA vaccine (Pfizer and Moderna). These vaccines instruct our cells to make a piece of the coronavirus’s hallmark spike protein in order to spark an immune system response. Another vaccine type delivers the code of the spike protein directly to cells to spark the immune response (J&J’s Janssen). A third type is more like a traditional vaccine that delivers a piece of the actual virus spike protein to the body to spark the immune response (Novavax). The upgrade with this type of vaccine is that it efficiently delivers an incredibly small piece of the virus (a nanoparticle). There is no chance that these vaccines change your DNA. Even after getting the vaccine you should continue to wear a mask around others, wash your hands, and practice physical distancing to prevent the virus from “hopping” from you to others even when you don’t get sick. Additional guidance on COVID-19 vaccines can be found on the MSCoE COVID-19 and Vaccine webpage.

Overall, vaccines and their boosters are safe and effective for people with MS and should be utilized based on current guidelines. 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. Vaccines should not be given during or within 4-6 weeks of an MS relapse. If you have any questions or concerns about vaccines, please talk with your health care provider.