Vaccine Safety and MS

Latest News July 31, 2013

Written by Susan Wells Courtney
Reviewed by Jack Burks, MD, MSAA’s Chief Medical Officer

Article summary: Published studies to date continue to affirm the safety of several vaccinations for individuals with MS. These vaccines (listed in this article) do not increase the risk of developing MS or exacerbating its symptoms. The safety of the shingles vaccine is more difficult to judge for individuals with MS, since this is a live-virus vaccine. Vaccines that use a live virus could pose a risk for individuals with compromised immune systems, resulting from an illness or a medication taken for an illness. The shingles vaccine is important for individuals 60 years and older, because the risk of developing shingles, as well as a painful long-term complication of shingles, greatly increases with age. Similar to the shingles vaccine, the yellow fever vaccine also uses a weakened, live virus. In a small study, the yellow fever vaccine was shown to increase MS disease activity. Before receiving any vaccine, individuals with MS should consult their physician to make sure that the specific vaccine and its timing is appropriate for them.

Vaccines Considered Safe for Individuals with MS

Published studies to date continue to affirm the safety of several vaccinations for individuals with MS. Researchers and national health organizations support the safety of the following vaccines for individuals with MS:

  • influenza (via the injected flu vaccine using inactivated viruses*)
  • hepatitis B
  • varicella (chickenpox)
  • tetanus
  • Bacille
  • Calmette-Guerin

These vaccines do not increase the risk of developing MS or exacerbating its symptoms. No evidence of a specific risk for relapse has been associated with any of these vaccinations.

*Please note that flu vaccines are usually available in two forms: injected and intranasal. The injected type of flu vaccine uses the inactivated (or killed) viruses, and according to many published studies as well as national health organizations, is considered safe for individuals with MS. People cannot develop the flu from the injected vaccines, since these contain non-infectious particles. The intranasal vaccine (“FluMist”), given by nose with a mist, contains live viruses and is NOT recommended for individuals with MS.

In a meta-analysis of immunization and MS (Rutschmann OT, et al, 2002), the authors evaluated and summarized the data from several published studies. They found no evidence that those vaccinations (listed above) increase the risk of an MS relapse. However, they did find strong evidence for an increased risk of an MS relapse in individuals with MS who become infected with one of the above-mentioned illnesses. Therefore, the authors conclude that evidence supports using strategies to reduce the risk of infection with one of these illnesses, and this can be most effectively accomplished through the use of vaccines deemed safe for individuals with MS.

Before receiving any vaccine, individuals with MS should consult their physician to make sure that the specific vaccine and its timing is appropriate for each individual. If experiencing a relapse, patients may be advised to wait a period of time (approximately four to six weeks) before receiving a vaccine.

If considering a vaccine containing a live virus (versus an inactivated virus), this should always be discussed in advance with one’s doctor. Several factors – including any medications someone has, is, or plans on taking – can play a large role in the safety of the vaccine. More information is provided in the next section of this article, which gives more details on the live-virus vaccine approved to reduce the risk of shingles. Additionally, for people who are taking or have taken certain medications (including Tysabri® [natalizumab], Gilenya® [fingolimod], and IVIG), more studies are needed to determine if these interfere with the effectiveness of certain vaccines.

In addition to the vaccines listed earlier, no evidence has been shown for an increased risk of developing MS as a result of the following vaccinations:

  • measles-mumps-rubella (MMR)
  • polio
  • typhoid fever
  • diphtheria

One meta-analysis (Farez MF, et al, 2011) found that vaccinations for diphtheria and tetanus may be associated with a decreased risk of developing MS. The authors note that further research is needed.

For more information on the flu and flu vaccines, please see the following articles from MSAA:
Flu and Flu Vaccine Information (posted January 2013)
Vaccination Safety (posted October 2012)
Flu Vaccines, MS, and General Flu and Cold Information (posted October 2004)

For additional information on all of the vaccines mentioned in this article, as well as general information on avoiding and treating the flu, please visit the CDC’s website

Other Vaccines and MS

Shingles (Herpes Zoster) Vaccine
According to the Centers for Disease Control and Prevention (CDC), the vaccine for shingles (also known as herpes zoster or zoster) is recommended for use in people 60 years and older to reduce the risk of shingles. This includes everyone in this age group who has no contraindications, as well as people who have had a previous episode of shingles and/or have chronic medical conditions. (The specific “chronic medical conditions” listed by the CDC include kidney failure, diabetes, rheumatoid arthritis, and chronic pulmonary disease.) The shingles vaccine was approved by the Food and Drug Administration (FDA) in 2006 and is marketed under the brand name Zostavax®.

The safety of the shingles vaccine is more difficult to judge for individuals with MS. The current data supporting its use are reassuring, but not complete because this vaccine has not been fully investigated in MS. The shingles vaccine has been more thoroughly investigated in other illnesses, including patients whose immune system may be compromised by their disease or by the drugs used to treat their disease.

The shingles vaccine is a live, attenuated vaccine, which can be an issue for individuals with MS. Most of the vaccines mentioned earlier in this article use viruses that have been inactivated (i.e., killed), so the virus has no chance of infecting anyone. The shingles vaccine contains live viruses, but these have been “attenuated,” meaning that their strength has been reduced to a point where they can’t infect someone with a healthy, uncompromised immune system.

As with many individuals with various other health conditions, a large number of individuals with MS take medications that may modulate or suppress their immune system. A live-virus vaccine may conceivably be able to infect someone whose immune system is not fully functioning, a result of either an illness or medications given to treat an illness.

In addition to some of the FDA-approved long-term disease-modifying therapies for MS, large doses or extended use of steroids, which are frequently prescribed to treat MS relapses, can also suppress the immune system. Less common treatments to be considered when evaluating the safety of the shingles vaccine include: experimental treatments for MS, such as those being studied in clinical trials with MS patients; off-label treatments, such as methotrexate and Imuran® (azathioprine); hematopoietic stem cell transplantation (HSCT); and antiviral medications.

Individuals with MS who are taking any type of medication that affects the immune system (such as disease-modifying therapies, steroids, or experimental therapies) are advised to talk to their doctor before getting a shingles vaccine. Their physician can assess the risks and benefits of the shingles vaccine in conjunction with the type of medication they are taking. For specifics on vaccine safety in regard to the different medications and treatments that affect the immune system, please refer to the bullet points in MSAA’s article, “Shingles Overview and Vaccine Safety.”

Additional Information on Shingles and the Shingles Vaccine
Shingles is caused by the reactivation of the varicella zoster virus (VZV), which is the same virus that causes varicella (chickenpox). This usually occurs decades after the initial chickenpox infection. The reactivation of this virus causes a painful rash with clusters of fluid-filled blisters. Lasting for weeks, months, or even years, postherpetic neuralgia (PHN) is the most common complication of shingles, and can cause chronic, sometimes excruciating pain in the area where the rash occurred. While most people only have one episode of shingles, second and third episodes are possible.

For older individuals with MS, the risk of shingles and its complications is just as great as for those without MS – and for individuals with MS who take immunosuppressive medications, the associated risks become even greater. Everyone’s risk of shingles greatly increases as they get older, particularly after the age of 50. The risk of developing PHN (causing continued chronic pain) as a complication of shingles increases with age, as does the likelihood of experiencing longer lasting and more severe pain with PHN. Additionally, individuals with compromised or suppressed immune systems are also more likely to experience complications from shingles.

No serious adverse events have been seen with the shingles vaccine, which has been tested in approximately 20,000 individuals (without MS) age 60 and older. The vaccine appears to be effective for at least six years, but may last longer. While older individuals may get the vaccine at any age, it appears to be the most effective in people 60 to 69 years. Studies have found that the shingles vaccine reduced the risk of shingles by 51 percent in older adults, reduced the risk of PHN by 67 percent, and also reduced the severity and duration of pain associated with PHN.

For more information about shingles, the shingles vaccine (Zostavax), specific vaccine safety information, insurance coverage, and helpful resources, please see MSAA’s article, “Shingles Overview and Vaccine Safety.”

Yellow Fever Vaccine

Similar to the shingles vaccine mentioned above, the yellow fever vaccine uses a weakened, live virus. In an article about yellow fever vaccination and relapse rate (Farez MF, et al, 2011), seven individuals with relapsing-remitting MS (RRMS) traveling to areas where yellow fever is common were studied. These individuals were each given a yellow fever vaccine. This small, unblinded study found that disease activity (in terms of relapse rate, active lesions, and other signs of disease activity) significantly increased following the vaccine, compared to 12 months before and nine months after receiving the vaccine.

The authors stress the importance of weighing the risk of exposure to yellow fever against the risk of an MS relapse. Yellow fever is a potentially fatal virus transmitted by mosquitoes in tropical and subtropical areas of South America and Africa. Individuals with MS are advised to consult their physician to determine the risks and benefits of the vaccine in their particular situations.

For more information about the yellow fever vaccine, please visit the CDC’s website at http://www.cdc.gov/vaccines/hcp/vis/vis-statements/yf.html#risk

For More Information

In addition to MSAA’s website, individuals may call MSAA at (800) 532-7667 for more information about MS and its treatments. Questions to MSAA’s Client Services Department may be emailed to MSquestions@mymsaa.org

References

Auriel E., et al, Seasonal and H1N1 influenza vaccines in MS: safety and compliance, Journal of the Neurological Sciences, vol. 314 (1-2), pp. 102-3, Mar 15, 2012.

Chen RT, et al, Epidemiology of autoimmune reactions induced by vaccination, Journal of Autoimmunity, vol. 16 (3) pp. 309-18, May 2001.

Confavreux C., et al, Vaccinations and the risk of relapse in multiple sclerosis, New England Journal of Medicine, vol. 344 (5), pp. 319-26, Feb. 2001.

DeStefano F, et al, Vaccinations and risk of central nervous system demyelinating diseases in adults, Archives of Neurology, vol. 60 (4), pp. 504-9, April 2003.

Farez MF, et al, Immunizations and risk of multiple sclerosis: systematic review and meta-analysis, Journal of Neurology, vol. 258 (7), pp. 1197-206, July 2011.

Farez MF, et al, Yellow fever vaccination and increased relapse rate in travelers with multiple sclerosis, Archives of Neurology, vol. 68 (10), pp. 1267-71, Oct. 2011.

Gout O, Vaccinations and multiple sclerosis, Neurological Sciences, vol. 22 (2), pp. 151-4, April 2001.

Harpaz R, et al, Recommendations of the Advisory Committee on Immunization Practices (ACIP), National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 2006.

Martinez-Sernandex V, et al, Central nervous system demyelinating diseases and recombinant hepatitis B vaccination: a critical systematic review of scientific production, Journal of Neurology, October 20, 2012 (epublication ahead of print) Rutschmann OT, et al, Immunization and MS: a summary of published evidence and recommendations, Neurology, vol. 59 (12) pp. 1837-43, Dec. 2002.

Miller AE, et al, A multicenter randomized, double-blind, placebo-controlled trial of influenza immunization in multiple sclerosis, Neurology, vol. 48 (2), pp. 312-14, Feb. 1997.

Sievers EJ, Heyneman CA, Relationship between vaccinations and multiple sclerosis, Annals of Pharmacotherapy, vol. 36 (1), pp. 160-2, Jan. 2002.

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