Vaccinations and MS
During the fall and winter months, many people with MS have questions regarding the safety and efficacy of vaccinations. The following update is based on the most recent information available regarding vaccinations and MS. Please use this information to speak to your family physician and neurologist regarding the potential benefits and risks of any given immunization.
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 the Public Health Agency of Canada.
Some immunizations have been studied for safety and efficacy in people with MS. Vaccinations for tetanus, hepatitis B and influenza did not appear to increase the short-term risk of relapses.i In another study, vaccination against hepatitis B, influenza, tetanus, measles, or rubella did not increase a person’s risk of developing MS or optic neuritis.ii
The following vaccinations do not have published studies related to their safety in multiple sclerosis. Please discuss these vaccinations with your physician and neurologist:
- Hepatitis A
- Human papillomavirus (HPV)
Yellow Fever Vaccination — A small, unblinded study 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. For people with MS who must travel to areas where yellow fever is common, the increased relapse risk needs to be carefully weighed against the likelihood of exposure to yellow fever, a potentially fatal illness.
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.
2012-2013 Injectable Seasonal Flu Vaccine (includes H1N1)
The 2012-2013 seasonal influenza (flu) immunization is a single preparation that provides immunity to three different flu virus strains: H3N2 virus, an influenza B virus, and this year's H1N1 virus.
The injectable flu vaccine, which is an ‘inactivated’ vaccine, is recommended for everyone over 6 months of age. It has been studied extensively in people with MS and is considered quite safe. The injectable flu vaccine may be taken by people who are taking an interferon medication, glatiramer acetate, mitoxantrone, natalizumab, or fingolimod. However it is not yet known whether the vaccine is as effective for those talking natalizumab or fingolimod.
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.
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).
Human papillomavirus vaccine — Gardasil® is designed to prevent the HPV 6, 11, 16 and/or 18-related cervical cancer, cervical dysplasias, vulvar and vaginal dysplasias, and condyloma acuminate in girls and women 9 to 26 years of age. Gardasil® is also authorized for use in males 9 to 26 years of age for the prevention of infection caused by HPV Types 6, 11, 16, and 18 and for anogenital warts. A case report described the onset of acute disseminated encephalomyelitis following the second immunization with Gardasil (Waldemann et al., 2009) and (Sutton et al., 2009) reported five patients who presented with multifocal or atypical demyelination syndromes within 21 days of the second or third immunization (three of whom had previously experienced clinical isolated episodes of neurological dysfunction). Pending the availability of further data, a thorough discussion with a physician about the potential benefits and risks of Gardasil should take place prior to administration. The NACI Recommendation Grade I states that the immunogenicity and efficacy of this vaccine has not been fully determined in people with MS and as such individuals may not derive benefit from this vaccine. Further study is required.
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.
Shingles vaccine — Zostavax — isn't as clear-cut as it is for some other vaccines. In general, MS specialists do not recommend any live-virus vaccine for people with MS because live-virus vaccines can cause an increase in disease activity. However, 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. However, each person needs to discuss the potential benefits and risks of this vaccine with her or his healthcare provider. In terms of the possible risks for a person with MS whose close family member receives this or any other live virus vaccine, MS specialists are not in agreement. This is another decision the person with MS needs to discuss with her or his physician.
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 medication, 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 see the Public Health Agency of Canada Frequently Asked Questions for additional information on vaccinations.