According to the Canadian Immunization Guide, Seventh Edition (2006) the Institute of Medicine (IOM) rejected any causal association between the vaccines for MMR (measles, mumps and rubella), hepatitis B and influenza vaccines and autism spectrum disorders or demyelinating disorders — including multiple sclerosis. Children and adults with these disorders may receive further immunization with MMR, hepatitis B and influenza vaccines, as well as other routinely recommended vaccines, without deferral. For more information please visit canada.ca.
A 2017 systematic review of the published studies of the role of vaccines in the risk of developing MS and or MS relapses1 found that: there was no change in risk of developing MS after receiving a vaccination against seasonal influenza, hepatitis B, human papillomavirus (HPV), measles-mumps-rubella, variola, tetanus, Bacillus Calmette-Guérin (BCG), polio, or diphtheria; nor was there an increased risk of relapse following vaccination against seasonal influenza2. Decisions about the potential benefits and risks of any given immunization should be made in consultation with your healthcare providers, including your family physician and neurologist.
The following vaccinations do not have published studies related to their safety in multiple sclerosis. Please discuss these vaccinations with your physician and neurologist: meningitis, typhoid, hepatitis A, pertussis and Japanese encephalitis.
Yellow Fever Vaccination — A small, unblinded study in 20113 found that people with relapsing-remitting MS who received the yellow fever vaccination prior to travel found a significantly increased risk of MS relapse during the six weeks following the vaccination when compared to the remainder of the two-year follow-up period. However, in another small study4 published in 2020, increased risk of relapse following the YFV was not observed, though authors suggest additional studies are necessary to confirm this finding. Individuals who must receive the yellow fever vaccine are encouraged to speak with their prescribing neurologist.
Varicella vaccine may be specifically considered for people with MS who have never had chicken pox, lack evidence of prior immunity, and are considering starting an MS medication that has the potential to suppress cell mediated immunity. The vaccine should be taken well before starting the therapy.
2020-2021 Injectable Seasonal Flu Vaccine
The World Health Organization (WHO) WHO has recommended the following strains be included in the trivalent vaccine: one influenza A(H1N1), one influenza A(H3N2), and one influenza B.
For the quadrivalent vaccines the World Health Organization (WHO) recommends that they contain the above three virus strains recommended for the trivalent vaccine, as well as an influenza B virus from the lineage that is not included in the trivalent vaccine.
The injectable flu vaccine may be taken by people who are taking an interferon medication (including pegylated interferon), glatiramer acetate, mitoxantrone, natalizumab, teriflunomide, dimethyl fumarate, alemtuzumab or fingolimod. Please note: individuals being treated with Lemtrada® should be given the inactivated flu vaccine six weeks before receiving their Lemtrada infusion and a person should not receive a live-virus vaccine following a course of Lemtrada™.
All necessary vaccinations should be administered at least 6 weeks before a person starts treatment with Ocrevus™. No live-attenuated or live vaccines should be given during treatment or following treatment until B-cells have returned to normal levels. Treatment with Mavenclad must not be initiated within 6 weeks after vaccination with live or attenuated live vaccines because of a risk of active vaccine infection. Patients must not be vaccinated with live or attenuated live vaccines during or after Mavenclad treatment as long as the patient’s white blood cell counts are not within normal limits.
Live, attenuated vaccines are generally not recommended for a person with MS because their ability to cause disease has been weakened but not totally inactivated. MS experts are not in agreement about the risks for a person with MS whose close family member receives a live-virus vaccine. The family should discuss with the neurologist how best to handle this situation.
People who are experiencing a serious relapse that affects their ability to carry out activities of daily living should defer vaccination until 4-6 weeks after the onset of the relapse.
FluMist® is a live-virus flu vaccine (sometimes called LAIV for "live attenuated influenza vaccine") that is delivered via a nasal spray. This live-virus vaccine is not recommended for people with MS. Live, attenuated vaccines are those whose biological activity has been reduced so that their ability to cause disease has been weakened but not totally inactivated.
A high-dose flu vaccine (Fluad®) is available for people over age 65. This high-dose vaccine has not been studied in people with MS of any age.
Varicella vaccine ─ This vaccine should be considered by people with MS who have never had chicken pox, lack evidence of prior immunity, and are considering starting an MS medication that has the potential to suppress cell mediated immunity – for example, fingolimod, natalizumab and alemtuzumab. The vaccine should be taken six weeks before starting the MS therapy.
Hepatitis B vaccine is recommended for all children, adolescents, and adults who are at risk of contracting this potentially life-threatening disease. In 2002, after carefully examining the published, peer-reviewed scientific and medical literature addressing the possible relationship between hepatitis B vaccination and diseases of the nervous system, the National Academy of Sciences’ Institute of Medicine (IOM) determined that there is no association between hepatitis B vaccination and the onset of multiple sclerosis. Please see the National Advisory Committee on Immunization (NACI). A 2017 systematic review of vaccine safety in MS concluded that the hepatitis B vaccine does not increase a person's risk of developing MS. (NMSS)
Human papillomavirus vaccine — GARDASIL®9 is a vaccine indicated in girls and women 9 through 45 years of age for the prevention of infection caused by the Human Papillomavirus (HPV) types 6, 11, 16, 18, 31, 33, 45, 52 and 58 and the following diseases associated with the HPV types included in the vaccine: cervical, vulvar, and vaginal cancer caused by HPV types 16, 18, 31, 33, 45, 52, and 58; genital warts (condyloma acuminata) caused by HPV types 6 and 11and precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58; and GARDASIL®9 is also indicated in girls and women 9 through 26 years of age for the prevention of anal cancer caused by HPV types 16, 18, 31, 33, 45, 52, and 58, anal intraepithelial neoplasia (AIN) grades 1, 2, and 3 caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.
GARDASIL®9 is indicated in boys and men 9 through 26 years of age for the prevention of infection caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58 and the following diseases associated with the HPV types included in the vaccine: anal cancer caused by HPV types 16, 18, 31, 33, 45, 52, and 58; genital warts (condyloma acuminata) caused by HPV types 6 and 11 and anal intraepithelial neoplasia (AIN) grades 1, 2, and 3 caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58.
According to Health Canada, studies published in the scientific and medical literature on the safety of Gardasil after being used in the general population were conducted in the United States and several countries in Europe. More than a million girls and women received Gardasil in these studies. The studies compared the number of cases of autoimmune diseases, cardiovascular diseases, and diseases related to the brain or nervous system (neurologic) in those that received Gardasil with those that did not. No safety concerns consistently linked to Gardasil were found in these studies.
Pneumococcal vaccines (Pneumovax® 23 - PPSV23) and Prevnar® 13-PCV13) - PCV13 protects against 13 types of penumococcal bacteria; PPSV23 protects against 23 types of pneumococcal bacteria. One dose of PDV13 is recommended for all adults 65 years or older who have not previously received the vaccine. A dose of PPSV23 should be given at least one year later. Both pneumococcal vaccines are inactivated and safe for people with MS.
Shingles vaccines — There are two types of shingles vaccines available. Live-virus (Zostavax) and non-live (Shingrix). In general, MS specialists do not recommend live-virus vaccines for people with MS because live-virus vaccines may cause an increase in disease activity. Zostavax is somewhat unique because most people have had chicken pox earlier in their lives and therefore already have the virus in their bodies. If a person has had chicken pox or tests positive for the antibodies, this would likely be a safe and beneficial vaccine to take.
Shingrix was demonstrated to be more than 90% effective in preventing shingles in people who are 50 years or older, including those 70 to 80 years of age and older in clinical studies. Shingrix maintained protection for four years. As with all vaccines, Shingrix may not fully protect all people who are vaccinated.
Smallpox vaccine — The smallpox vaccine has never been studied in people with MS. In addition, Canadian public health experts have stated that the mass vaccination of healthy people, as a preventive measure, is not recommended at this time due to the absence of a case of smallpox. This vaccine, however, is used to prevent a serious, generally fatal illness, and should be made available to any person with MS who is exposed to smallpox because the risks associated with not getting vaccinated would be too great.
People who are experiencing a serious relapse that affects their ability to carry out activities of daily living should put off the vaccination until 4-6 weeks after the onset of the relapse.
People on therapies that suppress the immune system (immunosuppressants), such as mitoxantrone, azathioprine, methotrexate, cyclophosphamide and/or chronic corticosteroid therapy should consult their neurologist before taking any live-virus vaccine. A person with a suppressed immune system would be at greater risk for developing the disease.
Inactivated vaccines are generally considered safe for individuals who are taking an interferon formulations, glatiramer acetate, mitoxantrone, natalizumab, or fingolimod.
People who have received immune globulin preparation in the past three months may not receive the full effect of a vaccine. People on natalizumab or fingolimod may not receive the full effect of a vaccine.
Please canada.ca for additional information on vaccinations.
1 New England Journal of Medicine (Confavreux et al., 2001)
2 Archives of Neurology (DeStefano et al., 2003)
3 Archives of Neurology (Farez & Correale, 2011)
4 Neurol Neuroimmunol Neuroinflamm (Huttner et al., 2020)
With information from the Government of Canada and the National MS Society (USA)