Vaccination and disease-modifying therapies
| Class | Vaccination | Comments | |
|---|---|---|---|
| Interferon β22–25 42 43 | Maintenance immunomodulatory | Safe and effective | - |
| Glatiramer acetate22 35 | Maintenance immunomodulatory | Safe. Inactivated influenza vaccine may be less effective | - |
| Teriflunomide32 44 45 | Maintenance immunomodulatory | Inactivated neoantigens (first vaccination) and recall antigens (re-exposure) have been found to be safe and effective. Live-attenuated vaccines should be avoided during treatment and for 6 months after stopping (SmPC recommendation) | The long half-life of teriflunomide should be considered (unless an accelerated elimination protocol is used) when contemplating vaccination with live-attenuated vaccines after stopping teriflunomide |
| Dimethyl fumarate32 43 | Maintenance immunosuppressive | Inactivated neoantigens and recall antigens have been found to be safe and effective. Live-attenuated vaccines should be avoided until lymphocyte counts have returned to above 800/mm3 after stopping treatment | MMR screening before starting treatment.* VZV screening is also advisable given the potential risk of persistent lymphopenia (<800/mm3)** |
| Fingolimod (and other sphingosine-1-phosphate–receptor modulators)23 32 46 47 | Maintenance immunosuppressive | During—and for up to 2 months after—treatment, inactivated vaccines may be less effective. Live-attenuated vaccines should be avoided during this period | MMR* and VZV** screening before starting treatment. HPV vaccination should be offered before starting treatment |
| Natalizumab22 23 32 48 | Maintenance immunosuppressive | Although immune responses to inactivated neoantigens and recall antigens have been found to be preserved, some studies have suggested that inactivated influenza vaccine may be less effective. Live-attenuated vaccines have not been studied and should, therefore, be avoided (in particular neurotropic viruses) | MMR screening before starting treatment.* VZV screening is also advisable given the potential risk of VZV-associated CNS infections/vasculitis** |
| Alemtuzumab32 41 | Immune reconstitution therapy | Although immune responses to inactivated neoantigens and recall antigens are preserved after alemtuzumab, vaccination within 6 months of treatment may result in a smaller proportion of responders. Live-attenuated vaccines are not recommended until immune reconstitution has occurred | MMR* and VZV** screening before starting treatment The SmPC recommends against the use of live-attenuated vaccines for at least 6 weeks before treatment, which differs from the ‘Green Book’ guidelines adopted in this manuscript |
| Cladribine32 35 | Immune reconstitution therapy | Not recommended until immune reconstitution has occurred | MMR* and VZV** screening before starting treatment |
| Ocrelizumab17 32 36 | Maintenance immunosuppressive | Non-live vaccines may be less effective. Live-attenuated vaccines have not been studied and should, therefore, be avoided during treatment and after discontinuation until B-cell repletion | MMR* and VZV** screening before starting treatment |
| Mitoxantrone22 32 | Immune reconstitution therapy | Inactivated influenza vaccine may be less effective. Live-attenuated vaccines are not recommended earlier than 3 months after the last dose of chemotherapy and/or until immune reconstitution has occurred | MMR* and VZV** screening before starting treatment |
| Haematopoietic stem cell transplant (HSCT)3 38 49 | Immune reconstitution therapy | Inactivated vaccines after haematopoietic stem cell transplant are safe and specific revaccination programmes have been recommended by the ECIL group. Live-attenuated vaccines are not recommended earlier than 24 months after the transplant and should only be considered in patients with no graft-versus-host disease and no ongoing immunosuppression | There is no evidence that inactivated vaccines trigger or worsen graft-versus-host disease. Donor immunisation with Live-attenuated vaccines is contraindicated 4 weeks before donation. Close contacts of haematopoietic stem cell transplant recipients should be immunised according to the national recommendations and special considerations apply when using live-attenuated vaccines† |
*People with MS without a reliable history of appropriate immunisation (ie, having received two doses of MMR) should be tested for measles and rubella antibodies.
**People with MS without a confirmed history of chickenpox or without documentation of a full course of vaccination against VZV should be tested for VZV antibodies.
†Close contacts who need VZV or MMR live-attenuated vaccines should be temporarily separated from the haematopoietic stem cell transplant recipient. People with MS who have received haematopoietic stem cell transplant should have no contact with the stools or diapers of infants who have received the rotavirus live-attenuated vaccines vaccine in the previous 4 weeks.
CNS, central nervous system; ECIL, European Conference on Infections in Leukaemia; HPV, human papillomavirus; MMR, measles, mumps and rubella; MS, multiple sclerosis; SmPC, summary of product characteristics; VZV, varicella-zoster virus.