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.
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.
Specific recommendations for people with MS
2015-2016 Injectable Seasonal Flu Vaccine (includes H1N1)
The 2015-16 inactivated seasonal influenza (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. Trivalent vaccines protect against three types of flu: the A/California/7/2009 (H1N1) pdm09-like virus; the A/Switzerland/971/2013 (H3N2)-like virus; the B/Phuket/3073/2013-like virus (a B/Yamagata lineage virus). Quadrivalent vaccines protect against the same three viruses plus an additional B virus (B/Brisbane/60/2008-like virus).
The 2015-16 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.
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.
FluMist® is a live-virus flu vaccine (sometimes called LAIV for "live attenuated influenza vaccine”) that is delivered via a nasal spray. This live-virus vaccine is not recommended for people with MS.
Hepatitis B vaccine. Recommended for all children, adolescents, and adults at risk of contracting this potentially life-threatening disease. 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.
Human papillomavirus vaccine (Gardasil®). 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®). 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.
Smallpox vaccine. 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.
Varicella vaccine. 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 JAMA, 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.