Many people with MS have concerns about the safety of routine vaccinations and vaccinations required for travel to other countries. The information about each vaccine is based upon the best-available evidence.
The Academy of Neurology, in collaboration with the Immunization Panel of the Multiple Sclerosis Council for Clinical Practice Guidelines, published a summary of evidence and recommendations regarding immunizations and MS. They concluded that:
The evidence supports strategies to minimize the risk of acquiring infectious diseases that may trigger MS relapses (also called attacks or exacerbations).
The influenza, hepatitis B, varicella and tetanus vaccines are safe for people with MS.
A 2017 systematic review of the published studies of the role of vaccines in the risk of developing MS and or MS relapses found:
- No change in risk of developing MS after vaccinations against seasonal influenza, hepatitis B, human papillomavirus (HPV), measles-mumps-rubella, variola, tetanus, Bacillus Calmette-Guérin (BCG), polio, or diphtheria;
- No increased risk of relapse following vaccination against seasonal influenza.
Decisions about the potential benefits and risks of any given immunization should be made in consultation with your healthcare providers, including your family physician and neurologist.
Information about Specific Vaccines
2017-2018 Injectable Seasonal Flu Vaccine
The composition of U.Sl influenza (flu) vaccines is reviewed annually by the Centers for Disease Control and updated to match circulating flu viruses.
- The 2017-18 inactivated seasonal flu immunization is recommended by the Centers for Disease Control and Prevention (CDC) for everyone over 6 months of age. The seasonal flu vaccine has been studied extensively in people with MS and is considered quite safe, regardless of the disease-modifying therapy they are taking. However, individuals being treated with Lemtrada® should be given the inactivated flu vaccine six weeks before receiving their Lemtrada infusion.
- The 2017-18 inactivated seasonal flu immunization is manufactured by several different companies under different brand names. Each is a single injection that provides immunity to three or four different flu viruses.
- For 2017-2018, U.S trivalent influenza vaccines protect against three types of flu: A/Michigan/45/2015 (H1N1) pdm09-like virus; A/Hong Kong/4801/2014 (H3N2)-like virus; and B/Brisbane/60/2008-like (B/Victoria lineage). Quadrivalent influenza vaccines protect against these three viruses and an additional influenza B virus -- B/Phuket/3073/2013-like virus (Yamagata lineage).
A high-dose inactivated flu vaccine (Fluzone High Dose) is available for people over age 65. The Centers for Disease Control does not specifically recommend the high-dose vaccine for people over age 65 and the high-dose vaccine has not been studied in people with MS of any age. For these reasons, the National MS Society continues to support influenza vaccination (flu shots) for people with MS but recommends that only the standard dose be used. If additional data for Fluzone high dose in MS patients become available, the recommendation may be revised.
Getting vaccinated before flu season begins is the most effective way to prevent flu. For this reason, the CDC recommends that people get a flu vaccine by the end of October, if possible. However, getting vaccinated later can still be beneficial. The CDC recommends a flu vaccination as long as influenze viruses are circulating, even into January or later.
Hepatitis B vaccine
- The hepatitis B vaccine is recommended for all children, adolescents and adults at risk of contracting this potentially life-threatening disease. Note: Reports of an increase in MS cases in France following vaccination for hepatitis B frightened many people into avoiding hepatitis B vaccinations. However, these reports confused a temporal relationship (diagnosis of MS following the vaccine) with a causal relationship (the vaccine caused MS). MS experts are in agreement that the vaccine does not cause MS to occur. Hepatitis B is a serious illness that can safely be prevented with the hepatitis B vaccination.
- Individuals at risk include anyone working in a job that involves contact with human blood, those who have diabetes and are under age 60, those who have sex with or live in the same house as a person with hepatitis B virus infection, and those who have sex with more than one partner. Additionally, people who live or travel outside the country for more than 6 months a year are also advised to get this vaccine.
- In 2002, the National Academy of Sciences' Institute of Medicine (IOM) determined that there is no association between hepatitis B vaccination and the onset of MS. A 2017 systematic review of vaccine safety in MS concluded that the hepatitis B vaccine does not increase a person's risk of developing MS.
Human papillomavirus vaccine (Gardasil®).
Pneumococcal vaccines (Pneumovax® 23 - PPSV23) and Prevnar® 13-PCV13)
- This vaccine 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 ages 9 to 26.
- One case report (Waldemann et al., 2009) described the onset of acute disseminated encephalomyelitis following the second immunization with Gardasil, 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). However, a recent large-scale study of patient registries in Denmark and Sweden (see below) found no increased risk of developing MS among nearly 800,000 who received this vaccine. Use of Gardasil should be preceded by a discussion between patient and physician regarding benefits and risks.
Shingles vaccine (Zostavax®)
- PCV13 protects against 13 types of penumococcal bacteria; PPSV23 protects against 23 types of pneumococcal bacteria.
- One dose of PDV13 is recommended for all adults 65 years or older who have not previously received the vaccine. A dose of PPSV23 should be given at least one year later.
- For adults 65 and older who have already received one or more doses of PPSV23, the dose of PCV13 should be given at least one year after receiving the most recent dose of PPSV23.
- Both pneumococcal vaccines are inactivated and safe for people with MS.
- According to the American Academy of Neurology recommendations on immunizations for people with MS, pneumococcal vaccine should be considered for individuals with compromised pulmonary function, including those who use a wheelchair on a full-time basis or are bed-bound.
- Zostavax, is a live-virus vaccine to prevent shingles. MS neurologists do not recommend live-virus vaccines for people with MS because these vaccines can lead to an increase in disease activity. However, Zostavax is an exception because most people have had chicken pox earlier in their lives and therefore already have the virus in their bodies. Each person needs to discuss the potential benefits and risks of this vaccine with her or his healthcare provider.
- While this vaccine has not been studied in people with MS, it should be made available to any person with MS directly exposed to smallpox as the risks associated with not getting vaccinated would be too great.
- This vaccine should be considered by 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 – for example, Gilenya® (fingolimod) and Lemtrada™ (alemtuzumab).
- The vaccine should be taken six weeks before starting the MS therapy.
Studies of Vaccine Safety and Effectiveness in People with MS
Some, but not all, immunizations have been evaluated for safety and efficacy in people with MS:
- A study by the Vaccines in Multiple Sclerosis Study Group published in 2001 in the New England Journal of Medicine found that vaccination for tetanus, hepatitis B or influenza did not appear to increase the short-term risk of relapses (also called attacks or exacerbations) in people with MS.
- A study by the National Immunization Program of the Centers for Disease Control and Prevention, published in the Archives of Neurology in 2003, found that vaccination against hepatitis B, influenza, tetanus, measles, or rubella did not increase a person’s risk of developing MS or optic neuritis (which is often a first symptom of MS).
- A small, unblinded study, published in the Archives of Neurology in 2011, of people with relapsing-remitting MS who received the yellow fever vaccination prior to travel, found a significantly increased risk of MS relapses 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 – which is a potentially fatal illness.
- A study of nearly four million girls and women identified in nationwide patient registries in Denmark and Sweden, published in the Journal of the American Medical Association, found no increased risk of developing MS among nearly 800,000 who received quadrivalent human papillomavirus vaccine (Gardasil®), designed to prevent cervical cancer.
- A review of data from the complete electronic medical health records of Kaiser Permanente Southern California between 2008 and 20011, published in JAMA Neurology, found no long-term association of vaccines with MS or any other acquired central nervous system demyelinating disease.
Summary Table of Vaccine Recommendations
Summary Table of Vaccine Recommendations
||Use in people with MS
|Injectable seasonal flu vaccine
|Flu-Mist® flu vaccine
|Fluzone® high-dose flu vaccine
|Gardisil® human papillomavirus vaccine (HPV)
|Hepatitis B vaccine
||Probably safe in individuals not on immunosuppressant medications
|Pneumovax® 23 and Prevnar® 13 pneumococcal vaccines
||Inactivated in most countries
||Probably safe; benefit likely outweighs any risks
||Considered safe; may reduce relapses
|Varivax® and Proquad® varicella vaccines
||Probably safe. Required prior to treatment with fingolimod and alemtuzumab in patients without previous exposure
|Yellow fever vaccine
||May not be safe; should not be used by individuals on immunosuppressant medications
|Zostavax® zoster vaccine
||Probably safe for any adult who has had chicken pox
Adapted from Williamson EML, Chahin S, Berger JR. Vaccines in multiple sclerosis. Curr Neurol Neurosci Rep
2016; 16:36. DOI 10.1007/s11910-016-0637-6