Figure 1.

Immunization strategy in pwMS. (a) Immunization strategy and immunosuppression: timings and precautions. a. For ocrelizumab and alemtuzumab according to the Summary of product characteristics. b. If absolute lymphocyte counts < 800/mm³ (grade 2 and 3 lymphopenia). c. In very exceptional cases, such as a high risk of infection, vaccination with live attenuated vaccines in patients treated with NTZ and DMF could be considered if the potential risk of acquiring the infection is superior to the risk of developing vaccine-related infections.

IS: immunosuppression; Ab: antibody; S1 P: selective sphingosin-1-phosphate-receptor-1; CLAD: cladribine; ALZ: alemtuzumab; DMF: dimethyl fumarate; TER: teriflunomide; NTZ: natalizumab.

(b) Recommended vaccines in special sub-populations (pregnancy, children, elderly and international travel). a. During any trimester at the beginning of the influenza season. b. During the third trimester of pregnancy (between week 20 and 36), unless national recommendations state otherwise. c. See Table 1. d. With a background of chickenpox disease or live-attenuated varicella vaccination (otherwise consider varicella immunization). e. Follow most updated local/country guidance on COVID-19 vaccination for high-risk patients.

dTap: diphtheria, tetanus and acellular pertussis; IS: immunosuppression; IPV: inactivated polio vaccine; OPV: oral polio vaccine.