Vaccination Recommendations Prior to Multiple Sclerosis Treatment
Patients with multiple sclerosis should receive all recommended vaccinations at least 4-6 weeks before starting immunosuppressive therapy, with particular attention to pneumococcal, influenza, hepatitis B, and varicella zoster vaccines. 1, 2
Core Vaccination Principles for MS Patients
- All vaccinations should be administered according to immunization guidelines at least 4 weeks prior to initiation of MS treatment for live or live-attenuated vaccines and at least 2 weeks prior for non-live vaccines 2
- Live-attenuated vaccines are contraindicated during immunosuppressive therapy and until B-cell repletion occurs 2, 3
- Vaccination should be considered before starting immunosuppressive treatment whenever the patient's clinical situation allows 4
Essential Vaccines Before MS Treatment
- Pneumococcal vaccination: Recommended due to increased risk of invasive pneumococcal disease in immunocompromised individuals 1
- Varicella zoster virus (VZV) vaccination: Particularly important for patients who will undergo immunosuppressive therapy due to high risk of herpes zoster infection 1, 2
- Hepatitis B vaccination: Screen for HBV before initiation of treatment; vaccinate if negative for surface antigen and antibodies 2, 5
- Influenza vaccination: Recommended annually 1, 3
- COVID-19 vaccination: Recommended following national guidelines 1, 6
Timing Based on Specific MS Treatments
- For ocrelizumab therapy: Complete all vaccinations at least 4-6 weeks before starting treatment 1, 7
- For immune-reconstitution therapies (alemtuzumab, cladribine): Delay vaccination until at least 6 months after the last course of treatment if already on therapy 1, 6
- For high-dose or long-term corticosteroids: Delay vaccination until 4-6 weeks after treatment cessation 6, 1
- For anti-CD20 therapies (rituximab, ocrelizumab): If already on therapy, vaccination should be delayed for at least 6 months after the last dose for optimal response 6, 1
Vaccine Types and Safety Considerations
- Inactivated vaccines (influenza, hepatitis B, pneumococcal): Generally safe for MS patients but may have reduced efficacy during immunosuppressive therapy 1, 8
- Live-attenuated vaccines (MMR, varicella, zoster): Contraindicated during immunosuppressive therapy; must be given at least 4 weeks before starting treatment 2, 3
- If immunosuppressive treatment is already established, live attenuated vaccines are absolutely contraindicated 4, 8
Practical Implementation
- The time needed for completing a pre-MS treatment vaccination protocol can be as short as 27 days (median) 9
- For vaccines with a correlate of protection, monitor the serological response 1-2 months after the last dose 4
- Hepatitis B vaccination should be prioritized early in the diagnosis process, as protective antibody formation is significantly better when vaccination occurs before treatment (193 mIU/ml) compared to after treatment (0 mIU/ml) 5
Important Caveats
- Disease-modifying therapies (DMTs) may reduce antibody response to vaccines, but vaccination is still strongly recommended 1, 8
- If a patient is experiencing an MS relapse, vaccination should be delayed until the relapse resolves 3
- For patients with active underlying disease, immunosuppressive therapy should be prioritized over vaccination if treatment cannot be delayed 6, 1
- Clinicians must screen for latent infections before starting immunosuppressive therapy according to prescribing information 3