CONCERN

Vaccination

Vaccination is an important preventative measure for our MS patients.

There is much debate whether a given therapy is immunosuppressive or not. In the author’s view, any therapy that can lead to any or all of the following is an immunosuppressive agent:

Causes sustained lymphopenia and/or neutropenia.
Associated with opportunistic infection such as PML, varicella encephalitis CMV or TB reactivation etc.
Leads to a reduced immune response following vaccination.

All oral and intravenous therapies for MS would thus qualify as an immunosuppressive agent.

We should then consider for all our MS patients the following issues with regards to vaccination:

Routine vaccination should be confirmed and brought up to date if necessary in all our MS patients.
History of infection does not guarantee immunity and whenever possible should be verified by serological testing especially for varicella virus.
All live attenuated vaccines should be avoided in patients who are presently receiving an immunosuppressive agent.
Additional vaccines should be administered in immunosuppressed patients.
Immune response to vaccination can be attenuated in immunosuppressed patients.
Ideally, vaccination should precede the onset of immunosuppressive therapy by 2 weeks for inactivated vaccines and 4 to 6 weeks for live vaccines.
Newly diagnosed and treatment naive MS patients offer an ideal opportunity to address all the above mentioned vaccination issues.

What are the routine immunizations that a healthy adult should have received?

What if the adult has never been immunized or the information is unknown?

Repeat/supplementary vaccination for measles, mumps, rubella, pneumococcus, haemophilus influenza type B , influenza pneumonia is not known to have any deleterious effect.
Patients who have had a serious vaccination reaction (Arthus phenomena) in the past should be evaluated by a specialist prior to initiating further vaccination.

Patients who are to receive or have already begun immunosuppressive therapy

Prior history of infection does not guarantee immunity.
Ideally, routine vaccination should be brought up to date prior to starting the disease modifying therapy, keeping in mind that inactivated vaccines should be given 2 weeks prior to starting therapy and live vaccines 4 to 6 weeks.
Live vaccines should only be administered at least 3 to 12 months after the end of the immunosuppressive therapy.
All family members should have their vaccination status brought up to date.
Once on immunosuppressive therapy, all live vaccines are contraindicated and inactivated vaccines may result in a diminished immune response.
Some inactivated vaccines are given in a modified calendar (see table).
Immunity following vaccination should verified when possible by serological testing.
Patients should receive supplemental inactivated vaccines: haemophilus influenza type B (Hib 1 dose), pneumococcus (conjugated version Pneumovax followed 8 weeks later by the polysaccharide version Prevnar13), Influenza (annual subcutaneous), Hepatitis B (3 doses or more if serology