Immunizations in Multiple Sclerosis: What You Need to Know

The information in this article is based on one of the most recent and authoritative scientific papers on vaccine-preventable infections and immunizations in patients with multiple sclerosis (MS) — “Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis” (Neurology, 2019). This document represents an updated guideline by the American Academy of Neurology (AAN), created by a multidisciplinary team of leading experts including neurologists, researchers, and clinicians with extensive academic and practical experience — Mauricio F. Farez, Jorge Correale, Melissa J. Armstrong, Alexander Rae-Grant, and others. Their recommendations and analyses, grounded in a systematic review of the scientific literature and rigorous evaluation of the evidence, have been accepted and endorsed by several professional organizations, including the Multiple Sclerosis Association of America and the Consortium of Multiple Sclerosis Centers.

The goal of the questions and answers presented here is to provide clarity and confidence for patients and their loved ones regarding the most important aspects of vaccination and infection prevention in MS — in the context of modern science and medical practice.

“Vaccination in multiple sclerosis does not increase the risk of relapses or disease progression — on the contrary, it protects both the patient and their community. Modern science recommends immunizations as a safe and effective method of protection for people with MS.”

Expert Opinions 

When it comes to patients with multiple sclerosis (MS) and vaccine-preventable infections, both patients and their families often face many questions: Can vaccines trigger a relapse? How do immunomodulatory therapies interact with immunizations? Is vaccination safe while taking certain medications? And most importantly: Are there specific recommendations proven to be effective and beneficial for patients?

Here are five key expert opinions and scientific findings from updated guidelines and studies published by the American Academy of Neurology (AAN) and leading specialists that will help patients, their families, and healthcare professionals navigate this important topic.

1. Vaccines Do Not Increase the Risk of Developing or Worsening Multiple Sclerosis

Question: Can vaccines cause MS or trigger a relapse? 

“There is no definite evidence suggesting that vaccination increases the risk of MS, although a link cannot be completely excluded, given the paucity of relevant data. Vaccinations against HPV, TT, pertussis, and smallpox were associated with a lower likelihood of a subsequent MS diagnosis.” 

Explanation: This means that when standard vaccination guidelines are followed, the risk for MS patients is not higher — and in some cases, it’s actually lower. The evidence does not support the widespread fear that vaccines can provoke MS or relapses.

2. Vaccination for People with MS Is Recommended, Following Local Standards

Question: What are the main vaccination recommendations for people with MS? 

“Clinicians should recommend that patients with MS follow all local vaccine standards (e.g., from the US CDC, WHO, and local regulatory bodies), unless there is a specific contraindication (e.g., active treatment with ISIM agents)... Clinicians should recommend that patients with MS receive the influenza vaccination annually, unless there is a specific contraindication.” 

Explanation: Adhering to local vaccination schedules and receiving the flu shot annually has proven benefits and does not increase the risk of complications in MS patients. However, consulting with a healthcare provider is crucial, especially before receiving live vaccines or when on specific treatment regimens.

3. When on Immunomodulatory/Immunosuppressive Therapy: Specific Rules and Extra Caution

Question: What should be considered when vaccinating MS patients who are taking specific medications? 

“Physicians should assess or reassess vaccination status of patients with MS before prescribing ISIM therapy and should vaccinate patients with MS, according to local regulatory standards and guided by treatment-specific infectious risks, at least 4–6 weeks before initiating ISIM therapy as advised by specific prescribing information (Level B). ... Clinicians should recommend against using live-attenuated vaccines in people with MS receiving ISIM therapies.” 

Explanation: If immunosuppressive therapy (e.g., medications such as fingolimod, alemtuzumab, natalizumab, etc.) is planned, vaccinations should be completed beforehand. While on these therapies, live vaccines should generally be avoided.

4. Vaccination During an MS Relapse Should Be Postponed

Question: When should vaccination be avoided in MS? 

“Clinicians should delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active...” 

Explanation: Vaccination during an active relapse may interfere with recovery or obscure the clinical picture. Therefore, it is recommended to wait until the relapse is resolved before administering vaccines.

5. Immunizations in MS Provide Dual Benefits — They Protect Both the Patient and the Community

Question: Do vaccines still matter for MS patients if they feel protected by their disease-modifying therapy? 

“In addition to conferring personal benefits, vaccination of the MS patient population contributes to the well-established phenomenon of herd immunity for the communities in which patients with MS live. Thus, vaccination of patients with MS is expected to have personal and population-level benefits.” 

Explanation: Vaccination not only protects the patient from potentially dangerous infections, but also helps reduce the spread of infectious diseases within the community. This is especially important for people with weakened immune systems, which often includes MS patients.

Questions and Answers

1. Question: If I’ve already had a vaccine-preventable infection (e.g., measles, chickenpox, hepatitis), does that increase my risk of developing MS? 

Answer: According to the systematic review in the article, there is not enough data to support or refute a connection between MS development and a history of infections such as diphtheria, hepatitis (unknown type), measles, meningitis, mumps, pertussis, polio, rubella, smallpox, tuberculosis, typhoid, or varicella-zoster virus (VZV). 

“Data were insufficient to support or refute an association between development of MS and a history of diphtheria, hepatitis (unknown type), measles, meningitis, mumps, pertussis, polio, rubella, smallpox, tuberculosis, typhoid, and zoster (varicella zoster virus [VZV], chicken pox, and herpes zoster).”

2. Question: If I’m currently undergoing treatment with certain MS medications, does that affect how effective vaccines are for me? 

Answer: Yes, some MS medications can reduce the effectiveness of certain vaccines. For example, patients on fingolimod, mitoxantrone, or glatiramer acetate may have a weaker response to the flu vaccine, although most still achieve adequate protection. With other medications like interferon beta (IFN-β), there’s no significant difference in response to the flu vaccine. 

“It is probable that individuals with MS receiving fingolimod therapy have a reduced likelihood of seroprotection from influenza vaccine... individuals with MS receiving mitoxantrone have a lower likelihood of response... whereas individuals with MS receiving IFN-β therapy do not have a meaningful reduction in the likelihood of seroprotection in response to influenza vaccination.”

3. Question: If I test positive for a latent infection (e.g., tuberculosis or hepatitis), can I still start immunosuppressive therapy for MS? 

Answer: Before starting immunosuppressive or immunomodulatory therapy, doctors must screen for latent infections such as hepatitis and tuberculosis. If results are positive, the latent infection must be treated before beginning MS therapy. 

“Clinicians must screen for certain infections (e.g., hepatitis, tuberculosis, and VZV) according to prescribing information before initiating the specific ISIM medication planned for use (Level A) and should treat patients testing positive for latent infections (e.g., hepatitis and tuberculosis) before MS treatment...”

4. Question: Are there situations where live (attenuated) vaccines can be used in MS patients, even though they’re generally not recommended? 

Answer: While live vaccines are usually avoided in patients on immunosuppressive therapy, in situations of high infection risk (e.g., during a pandemic or if an inactivated alternative is unavailable), a physician may consider using a live vaccine after carefully weighing the risks and benefits. 

“When the risk of infection is high, clinicians may recommend using live-attenuated vaccines if killed vaccines are unavailable for people with MS who are currently receiving ISIM therapies (Level C based on variation in patient preferences, benefit relative to harm, and importance of outcomes).”

5. Question: Why are vaccines sometimes postponed in MS patients on corticosteroid therapy? 

Answer: Live vaccines should be delayed for at least 3 months after stopping high-dose systemic corticosteroids because these medications suppress the immune response and may increase the risk of complications from live vaccines. 

“Corticosteroids used in greater than physiologic doses also may reduce the immune response to vaccines. Physicians should wait at least 3 months after discontinuation of therapy before administering a live-virus vaccine to patients who have received high-dose, systemic steroids for greater than or equal to 2 weeks.”

Conclusion 

In conclusion, the current guideline from the American Academy of Neurology provides reliable, evidence-based, and practical information for any patient with multiple sclerosis facing questions about immunizations and infections. The expert analysis by Mauricio F. Farez, Jorge Correale, Melissa J. Armstrong, Alexander Rae-Grant, and their co-authors serves as a valuable reference for both patients and physicians. The practical recommendations presented here reflect the most up-to-date understanding of the safety, efficacy, and importance of vaccinations in MS. By following these guidelines, patients can make informed choices that align personal protection with the latest advances in medical science.

Source Farez MF, Correale J, Armstrong MJ, et al. Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis. Neurology. 2019;93:584–594. doi:10.1212/WNL.0000000000008157