There are now a large number of different MS therapies. When choosing a therapy, it also plays a certain role whether and against which pathogens should be vaccinated. Especially in anticipation of a COVID19 vaccination, this is asked by many patients.
There is general agreement that inactivated vaccines do not cause harm even in immunosuppressed patients. However, data on the effectiveness of vaccinations in combination with the various available MS drugs are still incomplete.
In contrast to inactivated vaccines, live vaccines should not be used under immunosuppressive MS therapy. Nevertheless, there may be situations where the benefits and risks of a live vaccination must be weighed against each other, for example in MS patients undergoing fingolimod treatment who have not previously had contact with varicella (chickenpox) – here a varicella vaccination can be considered, as severe complications of the natural infection outweigh the risk of the live vaccination.
As for the timing of a vaccination in MS patients who are about to start immunosuppressive therapy, there is broad agreement. Vaccinations should generally be carried out early before treatment begins. At least 2 weeks should elapse between inactivated vaccines and the start of immune therapy, at least 4 – 6 weeks for live vaccines. The need for booster vaccinations during an immunotherapy should be noted, titer controls can help evaluate the success of vaccination.
Since the protective effect of vaccinations is mainly mediated by the formation of antibodies, vaccinations should be considered especially before the application of B-cell depleting therapies, especially vaccinations against encapsulated bacteria such as pneumococci. But also with therapies with alemtuzumab or cladribine it should be considered that B-cells are significantly suppressed after the start of therapy.
For many immunotherapies, proof of immunity to the chickenpox virus (Varicella zoster – VZV) is required. Those who do not yet have immunity should be vaccinated. In addition, VZV-seropositive patients (i.e., those who had chickenpox in the past, or were vaccinated against VZV in childhood), who undergo immunotherapy, should also be offered a vaccination against the reactivation of the chickenpox virus and its consequences (the painful shingles). A new inactivated vaccine against shingles (herpes zoster) has recently become available, which is recommended by the STIKO for people with chronic diseases/immunosuppression > 50 years old. As the European Medicines Agency EMA recently recommended extending the approval of the vaccine to 18 years with an increased risk for herpes zoster, it can be assumed that the STIKO recommendation for younger patients will also be adjusted.
Patients planned for Fingolimod or Alemtuzumab treatment should also be offered the option of vaccination against HPV, as there are reports of warts and cervical dysplasia in both MS therapies.
At the end of this small continuing education series on vaccinations, it can therefore be summarized that vaccinations are among the most effective and safest preventive measures in medicine. Modern vaccines are well tolerated, vaccination complications are only observed in rare cases, permanent damage is a rarity. Vaccinations have a much lower complication rate than the diseases they are intended to prevent. Vaccinations do not trigger MS, a change in disease activity is also unlikely. Vaccinations rather protect against infections or weaken them and thus offer protection against MS disease activity. Accordingly, all MS patients should receive vaccination protection according to the recommendations of the STIKO, especially in view of the fact that treatment with immunosuppressive therapies may become necessary during the course of the disease.
