The European Committee for Treatment and Research in MS (ECTRIMS) and the European Academy of Neurology (EAN) have published their first recommendations on vaccination in people with MS (Otero-Romero et al. Eur J Neurol 2023;30:2144-2176). The following is a summary of key recommendations for patients receiving higher-efficacy disease-modifying therapies (DMTs).
- Immunization status should be evaluated for all patients. The vaccination plan should document the patient’s vaccination needs based on natural immunity, vaccine history and serology (e.g. varicella, measles, mumps, rubella, tetanus, hepatitis B). Vaccinations should be administered at diagnosis or in the early stages of the disease. The vaccination status should be reassessed before initiating an immunosuppressive DMT.
- Inactivated vaccines should ideally be administered >2 weeks before initiating a DMT. For hepatitis B, tetanus, measles, mumps and varicella, measure vaccine-induced antibody titres 1–2 months after the last vaccine dose to ensure that there is a protective immune response. Consider a booster if there is an inadequate vaccine response.
- Live-attenuated vaccines can be given during treatment with a beta-interferon or glatiramer acetate, but should be administered >4 weeks before initiating other DMTs (>6 weeks for ocrelizumab or alemtuzumab).
- If an inactivated vaccine is required during treatment with ocrelizumab/rituximab, vaccinate at least 3 months after the last infusion (4-6 weeks before the next infusion).
- If patients have stopped treatment, delay vaccination with live vaccines in patients coming off DMF (until normal lymphocyte count), teriflunomide (3.5-24 months), fingolimod (>2 months), siponimod (4 weeks), ozanimod (3 months), ponesimod (2 weeks), natalizumab (>3 months), ocrelizumab (until B cell repletion, approx. 18 months), ofatumumab (until B cell repletion, approx. 40 weeks), cladribine (until normal lymphocyte count, approx. 30-90 weeks) and alemtuzumab (until normal lymphocyte count, approx. 12 months).
- All MS patients should receive annual vaccinations against influenza and pneumococcus.
- For MS patients being considered (or currently on) an immunosuppressive DMT, consider the following vaccines: human papillomavirus (HPV), herpes zoster, and hepatitis B.
- Inactivated vaccines can be administered during the second or third trimester (any time for influenza vaccine). Pregnant women should be advised to receive a Tdap (tetanus, diphtheria, pertussis) vaccine ideally between weeks 20 and 36 of pregnancy. Live-attenuated vaccines should be administered >1 month before pregnancy and are contraindicated during pregnancy. Live vaccines can be administered postpartum regardless of breastfeeding (except for yellow fever vaccine), and 4–6 weeks before starting an immunosuppressive DMT.
- Measure CD19+ B cell levels in infants who have been exposed to an anti-CD20 therapy during pregnancy. Delay administering a live-attenuated vaccine to the infant until B cell counts have recovered.
Click here to view the full text of the ECTRIMS/EAN recommendations: https://onlinelibrary.wiley.com/doi/10.1111/ene.15809
Correction: a previous version misattributed the recommendations to the AAN.